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 The Grove At Carvalho during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection surveillance system, as illness tracking did not include all resident illnesses and did not trend non-antibiotic cases. Staff also did not consistently follow EBP and TBP requirements: two CNAs transferred a resident on EBP without gowns or gloves, a nurse fed a resident on Contact Precautions without PPE, another nurse entered that room without PPE, and a nurse/CNA performed a wound dressing change on a resident on EBP without gowns. In addition, a resident’s nebulizer mask and tubing were repeatedly left open to air instead of being stored in a bag when not in use.
Failure to Monitor and Document Antibiotic Use: The facility did not consistently monitor antibiotic therapy or document review of antibiotic use in the resident record. An IP used McGeer criteria on paper and kept the forms in her office, but did not review all antibiotic use with providers or document the 48-hour time out in the chart. Two residents treated for suspected UTI were documented as meeting infection criteria on surveillance sheets even though the McGeer criteria did not support that finding, and the DON stated the IP should communicate with the physician and document the communication in the medical record.
Medication administration errors resulted in a 5% error rate when two nurses made two errors during a medication pass. One nurse gave a resident the wrong probiotic formula instead of the ordered product, and another nurse gave Zofran after breakfast even though it was ordered before meals. The DON stated nurses were expected to follow physician orders during med administration.
Unlocked treatment and medication carts were observed on the Oak Grove unit, including a treatment cart left in the hallway near the nurse's station while residents and staff were nearby and a medication cart left unlocked with residents sitting beside it. The cart contained topical treatments and other supplies, and the surveyor was able to open the drawers. The surveyor also found two opened bottles of Latanoprost eye drops without dates opened and a bottle of ProStat with an opened date that did not align with manufacturer guidance; the LPN and DON stated these items should be dated when opened and discarded per the manufacturer's instructions.
Kitchen Floor Not Kept Cleanable and Dry Surveyors observed missing and cracked tiles in the dishwashing room and in front of the 3-bay sink, with pooled gray standing water on the floor. The FSD said he knew about the damaged tiles and that staff used a dry mop after dishwashing, while the Maintenance Director said there were no current open work requests and noted the area was consistently wet. The Administrator stated the kitchen floor was expected to be in good repair, easily cleanable, and free of pooled water.
A resident with multiple comorbidities and dependence for transfers required a sit-to-stand mechanical lift with two-person assistance per therapy assessments and facility policy, but the ADL care plan and CNA care card did not specify the required number of staff or clearly reflect the mechanical lift requirement. An agency CNA, despite being informed that two staff were needed and offered help, performed a sit-to-stand lift transfer alone, during which the resident let go of the hand supports, slid from the sling to the floor, and sustained fractures of the distal tibia and fibula. After the injury, the resident returned from the ED with a fiberglass splint and non–weight-bearing orders, yet the care plans and care card inaccurately documented use of a CAM boot with related interventions, even though nursing staff and the DON confirmed the resident had only a fiberglass splint and no CAM boot, and the plans were not updated to reflect the actual splint care needs.
A resident with cerebral palsy, lower extremity weakness, and multiple comorbidities was care planned and documented by therapy to require a Sit/Stand Lift with two staff for all transfers. Facility policy required two staff for all mechanical lift transfers, and CNAs on the unit informed an agency CNA that this resident needed two-person assistance. Despite this, the agency CNA performed a Sit/Stand Lift transfer alone, with no second staff member in the room; during the transfer the resident released the hand supports, slid from the sling to the floor, and sustained fractures of the distal tibia and fibula. The resident reported that transfers had always been done with two staff before this event, and other staff interviews and documentation confirmed that the transfer was done by a single CNA in violation of policy.
A resident with multiple comorbidities and intact cognition sustained a left ankle fracture after sliding from a sit/stand lift and returned from the ED with a short leg splint and non‑weight‑bearing instructions. The care plan and TAR incorrectly identified the device as a CAM boot and included orders to apply skin prep to the left heel and remove the CAM boot to assess skin and for signs of swelling or infection. Licensed nurses on all shifts documented completion of these CAM boot‑related treatments even though the resident never had a CAM boot, only a splint with an Ace wrap. Interviews with the resident, several nurses, and the DON confirmed that staff knew the resident had a splint, not a CAM boot, and one nurse admitted she did not know what a CAM boot was and had not performed the documented treatments, demonstrating inaccurate documentation and failure to follow the actual orthopedic orders.
A resident with multiple chronic conditions, including cerebral palsy, DVT, muscle weakness, and a lumbar compression fracture, was care planned and assessed as dependent on staff for transfers, bed mobility, dressing, personal hygiene, bathing, grooming, toileting, and showers. Review of CNA ADL flow sheets over a two‑month period showed numerous days on all three shifts where all ADL care areas were left blank, despite facility policy requiring documentation of services provided and CNAs’ statements that ADLs must be documented in POC in the EMR by the end of each shift. The DON acknowledged CNA documentation had been an issue and affirmed that daily documentation should not be incomplete or left blank.
The facility did not conduct a comprehensive assessment to determine necessary resources for resident care during normal and emergency operations. The assessment lacked details on resident care needs, physical environment, equipment, and cultural factors. It also failed to include contracts with third parties and risk assessments. The Administrator admitted the assessment was incomplete and not specific to the facility's needs.
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) plan, lacking tracking methods, written goals, and regular project evaluations. The Administrator admitted to not maintaining meeting notes or records of past QAPI projects, and there was no current or previous Performance Improvement Project (PIP) in place. The facility could not provide documentation of QAPI minutes or PIPs, indicating a significant deficiency in their quality assurance processes.
A facility failed to protect a resident's privacy by using an unsecured text messaging app to communicate health information. The UM mistakenly believed the platform was encrypted, but it was not. Additionally, residents reported that USPS mail and packages were not delivered on Saturdays, as the receptionist responsible for sorting mail only worked weekdays, causing delays in mail distribution.
The facility did not ensure residents were aware of the grievance process, as nine residents reported not seeing postings or knowing how to file grievances other than verbally informing staff. Grievance forms were not easily visible, and the option for anonymous filing was not communicated. The Administrator acknowledged the lack of postings and resident awareness.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in care. A resident with end-stage renal disease consumed excess fluids due to staff's lack of awareness of a fluid restriction. Another resident with a urinary catheter did not receive appropriate care, as staff assumed independence. Additionally, care plans for psychotropic medication use were incomplete, and a gastrostomy tube care plan was accidentally canceled. These issues highlight inadequate care planning and communication among staff.
The facility failed to adhere to professional standards in medication administration and fluid management for several residents. A resident received Clonidine despite blood pressure readings below the prescribed parameter, risking hypotension. Two residents with fluid restrictions had inadequate documentation and communication, leading to excessive fluid intake. Additionally, insulin injection sites were not rotated for a diabetic resident, and a prescribed hand splint was not consistently used for another resident, indicating non-compliance with physician orders.
A facility failed to ensure a physician signed and dated all orders for a resident with multiple diagnoses, including diabetes and chronic kidney disease. The facility's policy requires orders to be signed every 30 or 60 days, but the last signed orders were from November 2024. The DON confirmed the non-compliance during an interview.
The facility failed to provide timely physician or NP visits for three residents, resulting in lapses in required oversight. A resident with chronic conditions did not receive visits every 30 days during the first 90 days of admission, with a 61-day gap between visits. Another resident experienced a 372-day gap between physician visits, despite being seen by an NP. A third resident had not been seen for 110 days, violating the 60-day visit requirement. These deficiencies indicate lapses in regulatory compliance for resident care.
A facility's Consultant Pharmacist failed to identify medication irregularities during monthly reviews for two residents. One resident received Ultram for pain levels below prescribed parameters, while another lacked documented rationale for ongoing PRN Xanax use. The pharmacist did not report these issues, assuming prescribers were aware of documentation requirements.
The facility failed to follow food safety standards, with unlabeled and expired food found in the main kitchen and nourishment areas. Beverages and desserts lacked proper labeling, and frozen omelets were improperly stored. Expired yogurts were not disposed of, as confirmed by the FSD.
Two residents were found to be self-administering medications without proper assessments or physician's orders. One resident with herpes viral keratitis was using Prednisolone Ophthalmic Suspension, and another with post-polio syndrome was using Fluticasone Nasal Spray. Both residents had their medications unsecured at their bedside, and facility staff confirmed that necessary evaluations and orders were not completed.
A resident with Alzheimer's and a history of falls did not have their call light within reach, contrary to facility policy and care plan requirements. Observations showed the call light was consistently out of reach, and staff interviews confirmed it should always be accessible.
The facility failed to notify physicians of significant changes in condition for two residents. One resident's STAT chest x-ray results were not communicated, delaying treatment decisions. Another resident exceeded their fluid restriction, but the physician was not informed of the non-compliance. These actions breached facility policies and regulatory standards.
A nurse failed to secure a vial of Lispro Insulin on a medication cart, leaving it unattended and accessible to residents. This action was against the facility's policy, which requires medication carts to be locked and inaccessible when not under direct supervision. The nurse admitted the oversight, and the Unit Manager confirmed the policy requirements.
Two residents in an LTC facility received inadequate pain management, with opioid medications administered outside prescribed parameters. One resident with chronic pain syndrome and rheumatoid arthritis lacked a comprehensive care plan, while another resident received Hydromorphone for pain levels below the prescribed range. Staff interviews confirmed these deficiencies in pain management practices.
A resident with severe cognitive impairment was administered two antibiotics, Augmentin and Bactrim, concurrently without adequate clinical indications. The resident's daughter expressed concerns about a possible infection, leading to the initiation of Augmentin before urinalysis results confirmed a UTI. A physician later prescribed Bactrim, suspecting aspiration pneumonia, but was unaware of the ongoing Augmentin treatment. The facility delayed reviewing chest x-ray results, which showed clear lungs, indicating a lack of communication and oversight in medication administration.
The facility failed to monitor a resident for side effects of an antianxiety medication and did not document a rationale for the continued use of a PRN psychotropic medication for another resident. Despite minimal use and observations of calm behavior, the facility extended the PRN order without proper documentation of necessity or effectiveness, contrary to its policies.
A facility failed to maintain an accurate medical record for a resident admitted in October 2024. Only one progress note was initially available, despite the resident being active and having a hospital leave. The process involved the receptionist receiving and scanning notes into the record, but no additional notes were found. An NP was surprised by the lack of documentation, and later, additional notes were added. The DON acknowledged the issue and suspected a problem with the physician's computer system.
A nurse failed to perform hand hygiene between glove changes during wound care for a resident with a stage 4 pressure ulcer and a G-tube. The nurse admitted to not having hand sanitizer available, and the DON confirmed the expectation for hand hygiene between glove changes.
A resident with severe cognitive impairment was inappropriately treated with dual antibiotics for a UTI, despite not meeting the facility's McGeer criteria. The resident was prescribed Augmentin following a family request and later received Bactrim DS without the attending physician's knowledge of the ongoing treatment. This oversight violated the facility's antibiotic stewardship program, as there was a lack of communication and monitoring of the resident's antibiotic use.
The facility did not ensure that survey results and plans of correction were easily accessible to residents and their representatives. Nine residents were unaware of the availability of these documents, and a surveyor found the survey results binder inaccessible behind the reception desk. The Administrator was not aware of this issue.
The facility did not notify the State agency of a change in the Administrator. The current Administrator began on December 27, 2023, but the last update in the HCFRS was on October 30, 2023. The Director of Operations confirmed the oversight, believing the previous DON had updated the information.
A resident with an activated Health Care Proxy and on hospice care was found fully clothed in a bathtub with cold water running. Despite facility policy, the Health Care Agent was not notified until six hours later by the hospice nurse. The incident was reported to the Director of Nurses and the physician, but the full details were not communicated. Facility staff interviews revealed an expectation for immediate notification, which was not met, leading to a delay in informing the HCA.
A resident with a complex medical history was found in a bathtub with cold water, fully clothed, and visibly shivering. Despite the situation, the nursing staff failed to assess and document the resident's vital signs immediately after the incident, which is against the facility's policies and standard nursing practices. Interviews with staff confirmed the lack of documentation and assessment, indicating a significant oversight in care.
A resident under hospice care was found in a bathtub with cold water running, visibly cold and shivering. The facility failed to notify the hospice agency immediately, as required by policy, resulting in a six-hour delay. Staff interviews revealed a lack of communication and responsibility in reporting the incident.
Infection Surveillance, PPE Use, and Nebulizer Storage Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program with complete surveillance to identify trends of actual or potential infections. The Infection Preventionist stated she used McGeer Criteria and kept completed surveillance documents in her office. Facility line listings for December 2025 through March 2026 showed every resident listed each month met McGeer criteria for infection and every one was started on antibiotics. However, Resident #59 had a documented complaint of dysuria on 3/23/26, had recently completed antibiotics for a UTI, and had a follow-up urine obtained, but the March 2026 line listing did not include this illness. The line listing sheets also did not show tracking or trending of illnesses that were not treated with antibiotics. The Infection Preventionist stated she gathered illness information from resident records and morning report and completed surveillance sheets for COVID-19 and influenza outbreaks, but did not track day-to-day illnesses that did not require antibiotics. The facility also failed to ensure appropriate PPE use for residents on Enhanced Barrier Precautions and Transmission-Based Precautions. Resident #11 had diagnoses including a history of VRE, pressure ulcers, a G-tube, and an indwelling urinary catheter, and had an order for Enhanced Barrier Precautions related to VRE, G-tube, Foley, and wounds. During observation, two CNAs transferred the resident using a Hoyer lift and cloth pad without wearing gowns or gloves. Resident #23 had ESBL in the urine and an order for Contact Precautions. During observation, a nurse fed the resident breakfast while seated on the bed and did not wear a gown or gloves, and another nurse entered the room and removed the breakfast tray without donning PPE. Resident #5 had pressure ulcers and a Foley catheter and was ordered to remain on Enhanced Barrier Precautions. During a dressing change to the right heel, a nurse and CNA were observed without gowns. Staff later stated they believed PPE was only needed for certain direct care tasks, while the Infection Preventionist and DON stated the posted precautions required gowns and gloves for high-contact care and prior to entering rooms on contact precautions. The facility also failed to store Resident #15’s nebulizer equipment in a sanitary manner. The resident had diagnoses including Parkinson’s disease and COPD, a moderate cognitive impairment, and orders for nebulizer treatments and for nebulizer tubing to be changed weekly and labeled and dated. On multiple observations, the resident’s nebulizer mask and tubing were left open to air on top of the nebulizer machine on the bedside nightstand. Nursing staff stated the equipment should be placed in a bag when not in use and should not be left open to air. The DON stated nebulizer equipment should be changed weekly and stored in a bag when not in use.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not consistently monitoring antibiotic use and not documenting review of antibiotic therapy in the resident record. The facility’s policies stated that antibiotics were to be prescribed and administered under the guidance of the Antibiotic Stewardship Program, that antibiotic use would be monitored, and that the Infection Preventionist would track infections and communicate infection-related information to staff and prescribing practitioners. The Infection Preventionist stated she used McGeer criteria to determine whether an illness met criteria for infection requiring antibiotics, completed the criteria on paper, and kept the documents in her office. For Resident #11, who had a urinary catheter and was treated with Ceftriaxone for a concern for UTI, the surveillance sheet stated empiric treatment was started because of signs and symptoms and that a 48-hour time out was completed, even though no lab services were completed due to weather. However, the resident’s McGeer criteria showed only one criterion was met, no urine specimen was completed, and the concern did not meet criteria for infection. The medical record did not show that a 48-hour time out had been completed even though the symptoms did not meet criteria for infection. For Resident #59, who did not have a urinary catheter and was treated with Bactrim for a concern for UTI, the surveillance sheet also stated empiric treatment was started because of signs and symptoms, no lab services were completed due to weather, and a 48-hour time out was completed. The resident’s McGeer criteria indicated the concern met infection criteria, but the record did not show that a 48-hour time out had been completed even though the symptoms did not meet criteria for infection. During interview, the Infection Preventionist said she had not been reviewing all antibiotic use with providers and that both McGeer criteria documents were completed inaccurately; the DON stated the IP should communicate with the physician regarding antibiotics that do not meet criteria and document the communication in the medical record.
Medication Administration Errors During Medication Pass
Penalty
Summary
Medication administration errors occurred when two of three nurses observed during a medication pass made two errors out of 39 opportunities, resulting in a 5% medication error rate. The facility failed to ensure it was free from a medication error rate of 5% or greater. The report cites the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, which states that licensed nurses accept, verify, transcribe, and implement orders from authorized prescribers, and the facility policy requiring medications to be administered according to prescriber orders and verified for the right resident, medication, dosage, time, and route before administration. For one resident, a nurse administered Lactobacillus acidophilus even though the physician’s order was for Lactobacillus rhamnosus 1 capsule by mouth in the morning. During interview, the nurse stated the facility supplies Lactobacillus acidophilus and said the resident’s order should be changed. For another resident, a nurse administered Zofran 4 mg before meals, but it was given at 9:11 A.M. and at least one hour after breakfast, despite the order being for before meals. The nurse stated the medication should be scheduled earlier so it could be given before breakfast. The DON stated it was her expectation that nurses follow physician’s orders during medication administration.
Unlocked Treatment Cart and Undated Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in a safe and secure manner. On the Oak Grove unit, a treatment cart containing numerous topical treatments, prescription creams, ointments, and other treatment supplies was left unlocked in the hallway beside the nurse's station and remained accessible while residents and unlicensed staff were in the area. The cart was observed multiple times over the course of the afternoon in the hallway near the nurse's station, with residents congregating nearby, and the surveyor was able to open all drawers while the cart was unattended. Nurse #6, who was assigned to the cart, was not present during several of the observations, and the Director of Nursing stated that medication and treatment carts should be locked when the nurse is not at the cart. The facility also failed to ensure medications were dated when opened and discarded according to manufacturer guidelines in one of the medication carts. During observation of the Oak Grove medication cart, two opened bottles of Latanoprost eye drops for a resident were found without dates opened, even though the manufacturer instructions required discard six weeks after opening. The surveyor also found a bottle of ProStat labeled with an opened date of 12/15/25, and the manufacturer instructions required discard three months after opening. Nurse #6 stated that Latanoprost bottles should be labeled with the date opened and medications should be discarded per the manufacturer's instructions, and the DON gave the same statement during interview.
Kitchen Floor Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in the main kitchen. Surveyors observed several missing tiles and/or partial or cracked tiles in the dishwashing room and in front of the 3-bay sink, with pooled gray standing water present on the floor. These conditions were observed on multiple occasions during the survey, and the report states that the kitchen floor was not maintained in a sanitary and safe condition and was not free of standing water. The Food Service Director stated he was aware of the broken and missing tiles and had entered a work request with maintenance to have them fixed. He also stated staff used a dry mop after dishes were done to clean pooled water and that the kitchen was cleaned according to a routine schedule kept in a binder. The Maintenance Director stated there were no current open work requests for the kitchen tile floor and said the tiles had last been updated about two years earlier, noting difficulty replacing tiles in the consistently wet area. The Administrator stated he expected the kitchen tile floor to be in good repair, easily cleanable, and free of pooled water.
Failure to Specify Transfer Assistance and Accurately Care Plan Post-Fracture Splint
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized comprehensive care plan that clearly specified transfer assistance needs, including the required number of staff for mechanical lift transfers, for a resident who was dependent on staff for transfers. The resident, admitted with diagnoses including cerebral palsy, lower extremity DVT, muscle weakness, lumbar compression fracture, and other conditions, was cognitively intact and required a sit-to-stand mechanical lift and maximal assistance of two staff for all transfers per occupational therapy assessments. The resident’s ADL care plan and Resident Care Card, which were to guide direct care staff, documented that the resident required physical assistance to dependence with transfers but did not indicate the number of staff required or that a mechanical lift with two staff was needed, despite facility policy requiring two staff for mechanical lift transfers. On the evening of the incident, an agency CNA working his first shift at the facility received report that the resident required a sit-to-stand lift for transfers and acknowledged he knew that such transfers required two staff. Although another CNA on the unit told him that the resident required two-person assistance with the sit-to-stand lift and offered to help, the agency CNA proceeded to transfer the resident alone using the sit-to-stand lift. During this transfer, the resident let go of the hand supports and slid out of the lift sling onto the floor. The resident reported that there had always been two staff present for prior sit-to-stand transfers and that on the day of the fall a single male CNA transferred them without assistance. Nursing staff documented and reported that the resident fell from the sit-to-stand lift during the transfer and complained of left ankle pain. Following the fall, the resident was evaluated in the emergency department and diagnosed with fractures of the distal left tibia and fibula, and a short leg fiberglass splint with an Ace wrap was applied with orders for non-weight-bearing status and to keep the splint on. Subsequent orthopedic consultations directed that the splint remain in place and that the resident remain non-weight-bearing. However, the resident’s updated care plans and Resident Care Card inaccurately documented that the resident had a CAM boot to the left lower extremity when out of bed, with interventions to encourage use of the CAM boot and to check circulation, sensation, motion (CSM) and skin integrity while the boot was on. Multiple nurses, including the DON, confirmed that the resident did not have a CAM boot but instead had a fiberglass splint with an Ace wrap, and staff were unable to locate any CAM boot for the resident. The DON acknowledged that the care plans were not accurate, had not been updated after the orthopedic consults, and should have reflected the fiberglass splint and appropriate interventions, goals, and outcomes related to the fracture and splint care.
Failure to Use Two-Person Assist for Sit/Stand Lift Transfer Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers and adequate supervision for a dependent resident who required a Sit/Stand Lift with two staff assisting for all transfers. Facility policy, revised in May 2025, required that two staff members be utilized for all mechanical lift transfers, including sit-to-stand lifts, and that staff maintain compliance with safe handling and transfer practices. The resident’s care plan, Resident Care Card, and an occupational therapy recertification and updated therapy plan dated 12/29/25 all documented that the resident was dependent for transfers, required a Sit/Stand Lift for all transfers, and needed moderate to maximal assistance of two staff members. The resident, admitted in March 2024, had diagnoses including cerebral palsy, embolism and thrombosis of deep veins of the left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis, and a wedge compression fracture of the fifth lumbar vertebra. A quarterly MDS showed the resident was cognitively intact (BIMS 15) but dependent on staff for transfers. Therapy staff, including the COTA and OT, confirmed in interviews that prior to the fall the resident had experienced functional decline, had weak lower extremities, and required a Sit/Stand Lift with maximal assistance of two staff members for all transfers. On the evening of 01/01/26, CNA #1, an agency CNA with 18 years of experience, transferred the resident using a Sit/Stand Lift without another staff member present in the room, despite knowing that two staff were required for such transfers and having been informed at shift report that the resident required two-person assistance. During the transfer, the resident let go of the hand supports, slid out of the sling, and fell to the floor, subsequently complaining of left ankle pain. The facility’s HCFRS report and hospital ED documentation indicated the resident sustained fractures of the distal left tibia and fibula and was placed in a short leg fiberglass splint. The resident reported that previously there had always been two staff present during Sit/Stand Lift transfers, and another CNA stated she had offered to assist but was never called. Nursing staff interviews and progress notes corroborated that the fall occurred during a Sit/Stand Lift transfer and that the transfer had been performed by CNA #1 without the assistance of another staff member, while the DON was unable to clearly state the facility’s specific policy for Sit/Stand Lift staffing at the time of the survey.
Failure to Provide Accurate Orthotic Care and Honest Documentation After Ankle Fracture
Penalty
Summary
Nursing staff failed to provide care and services that met professional standards of quality for a resident who sustained a fracture of the distal left tibia and fibula after sliding from a sit/stand lift during a transfer. The resident, who had cerebral palsy, a history of deep vein thrombosis of the left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis, and a lumbar compression fracture, was cognitively intact but dependent on staff for transfers. Following the fall, the resident was evaluated in the emergency department, where a short leg fiberglass splint was applied to the left lower extremity and the resident was returned to the facility with the splint in place and non‑weight‑bearing instructions. Despite this, the resident’s care plan and Treatment Administration Record (TAR) documented that the resident had a Controlled Ankle Motion (CAM) boot on the left lower extremity when out of bed, with orders to apply skin prep to the left heel each shift and to remove the CAM boot as tolerated to assess skin for breakdown, swelling, or infection. These treatments were signed off as completed by licensed nurses on all shifts from early January through early February, even though the resident was never fitted with and never had a CAM boot. Orthopedic consultations later confirmed that the resident was to keep the splint on the left lower extremity and remain non‑weight‑bearing, and surveyor observation showed the resident wearing only a splint with an Ace wrap, with no CAM boot available. Interviews with the resident and multiple nurses revealed that staff knew the resident had a splint with an Ace wrap, not a CAM boot, and that the splint had not been removed. One nurse admitted she did not know what a CAM boot was, acknowledged that the resident did not have one, and stated she had not applied skin prep to the left heel or removed a CAM boot, despite having signed the TAR indicating those treatments were done. Other nurses and the DON consistently stated that the resident returned from the hospital with a splint, not a CAM boot, and that the TAR and treatment orders were not updated to reflect the actual orthotic device and required nursing care. This resulted in documentation of care and treatments that could not have been performed as ordered, and a failure to systematically assess and implement the correct prescribed medical regimen in accordance with professional standards.
Incomplete CNA ADL Documentation for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident who was dependent on staff for Activities of Daily Living (ADLs). Facility policy on charting and documentation, dated May 2023, required that services provided, progress toward care plan goals, changes in condition, and objective observations, treatments, or services be documented in the resident’s medical record. Resident #1, admitted in March 2024 with diagnoses including cerebral palsy, deep vein thrombosis of the left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis, and a wedge compression fracture of the fifth lumbar vertebra, had a care plan and MDS indicating dependence on staff for transfers, bed mobility, dressing, personal hygiene, bathing, grooming, toileting, and showers. Review of this resident’s CNA ADL flow sheets for December 1–31, 2025, and January 1–31, 2026, showed multiple instances where documentation for all ADL care areas on all three shifts was left blank. In December, the 7 a.m.–3 p.m. shift had 6 days with blank ADL areas, the 3 p.m.–11 p.m. shift had 17 days with blanks, and the 11 p.m.–7 a.m. shift had 20 days with blanks. In January, the 7 a.m.–3 p.m. shift had 7 days with blanks, the 3 p.m.–11 p.m. shift had 18 days with blanks, and the 11 p.m.–7 a.m. shift had 24 days with blanks. Multiple CNAs stated in interviews that ADL documentation is done in Point of Care (POC) in the EMR and must be completed by the end of each shift. The DON acknowledged that CNA documentation had been an ongoing issue, confirmed that CNAs are expected to document all care provided by the end of every shift, and stated that daily documentation should not be incomplete or left blank.
Facility Fails to Conduct Comprehensive Assessment
Penalty
Summary
The facility failed to conduct and implement a comprehensive facility-wide assessment that included the necessary resources to provide both emergency and day-to-day care for the resident population. The review of the Centers for Medicare and Medicaid Services (CMS) memo indicated that the facility assessment should involve active participation from the resident population and consider their care requirements, physical environment, equipment, and any ethnic, cultural, or religious factors affecting care. Additionally, the facility's resources, including buildings, equipment, and agreements with third parties for services during normal and emergency operations, should be assessed. However, the facility's assessment, last updated on 1/28/25, did not include these critical elements. During an interview, the Administrator acknowledged that the facility assessment provided to surveyors was the most updated version but admitted it was missing key elements and was not specific to the facility. The assessment lacked details on the resident population's care needs, the necessary physical environment and equipment, and any ethnic, cultural, or religious factors affecting care. Furthermore, it did not include a list of contracts and agreements with third parties or a facility-based and community-based risk assessment. The Administrator recognized that the assessment should have been more specific to the facility's population and needs.
Deficiency in Quality Assurance Processes
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee effectively identified quality deficient areas and implemented appropriate corrective action plans. Specifically, the facility did not develop or implement a Quality Assurance Performance Improvement (QAPI) plan or a Performance Improvement Project (PIP) that focused on high-risk or problem-prone areas identified through data collection and analysis. The facility's policy outlined a comprehensive approach to QAPI, including the establishment of a data-driven, proactive program to improve quality of care and services. However, the facility did not adhere to these guidelines, as evidenced by the lack of tracking methods, written goals, and regular comparisons of projects. During an interview, the Administrator admitted that while the QAPI committee met regularly, there was no system in place to track the effectiveness of QAPI projects or to determine if they needed re-evaluation. The Administrator also acknowledged that meeting notes and records of past QAPI projects were not maintained until recently, and there was no current or previous PIP in place. At the end of the survey, the facility was unable to provide any additional documentation or evidence of QAPI minutes or PIPs, highlighting a significant deficiency in their quality assurance processes.
Breach of Resident Privacy and Delayed Mail Delivery
Penalty
Summary
The facility failed to protect the personal privacy and confidentiality of Resident #337 by allowing the Unit Manager (UM) to communicate the resident's private health information via an unsecured text messaging application on a personal cell phone. The UM believed the platform was encrypted, but it was not, and the Director of Nursing (DON) confirmed that the resident's physician and nurse practitioner did not use a secure messaging platform. The text message included the resident's full name, change in medical condition, and treatment plan, which should have been communicated through a secure method, such as a phone call. Additionally, the facility did not ensure that United States Postal Service (USPS) mail and packages were promptly delivered to residents within 24 hours of delivery. During a resident group meeting, nine residents reported that mail and packages were not delivered on Saturdays because the receptionist, who is responsible for sorting and distributing mail, only works Monday through Friday. As a result, mail delivered on Saturdays was not distributed until the following Monday, delaying residents' access to their mail.
Facility Fails to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were fully aware of the grievance process, as observed during a resident group meeting attended by nine residents from three different units. These residents reported that they had not seen any postings about the grievance process and were unaware of how to file a grievance other than verbally informing a staff member. They were also not informed about the availability of grievance forms or the option to file grievances anonymously. This lack of awareness among residents indicates a failure in the facility's communication and implementation of its grievance policy. During a tour of the facility, the surveyor noted the absence of visible postings about the grievance process on the second-floor unit and found that the grievance forms were not easily accessible or visible due to their placement in a black wire mesh file holder. The sign above the file holder did not mention the availability of grievance forms or the option for anonymous filing. The Administrator, who is the Grievance Officer, acknowledged the oversight and confirmed that there were no postings to inform residents about the grievance process or the availability of forms, and he was unaware that residents did not know they could file grievances anonymously.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. For one resident with end-stage renal disease, the facility did not enforce a prescribed fluid restriction, resulting in the resident consuming more fluids than allowed. Staff, including CNAs and nurses, were unaware of the fluid restriction, and the resident was frequently observed with excess fluids at their bedside. The facility's failure to communicate and implement the care plan led to non-compliance with the resident's medical needs. Another resident with a urinary catheter did not receive appropriate catheter care as outlined in their care plan. The resident was independent in their activities of daily living, and staff assumed the resident was managing their catheter care independently. However, the care plan required staff to provide catheter care every shift, which was not being done. The resident was using alcohol wipes to clean the catheter tubing, which was not appropriate and could contribute to infections. The care plan was not individualized to reflect the resident's independence and actual care needs. Additionally, the facility failed to develop care plans for residents using psychotropic medications, lacking specific targeted behaviors, non-pharmacological interventions, and measurable goals. One resident with a gastrostomy tube did not have a care plan in place after it was accidentally canceled by the dietitian. These oversights indicate a lack of proper care planning and communication among staff, leading to inadequate care for the residents involved.
Failure to Adhere to Professional Standards in Medication and Fluid Management
Penalty
Summary
The facility failed to adhere to professional standards of practice in administering medications and managing fluid restrictions for several residents. For one resident, Clonidine, an antihypertensive drug, was administered despite the systolic blood pressure being below the prescribed parameter of greater than 180, on multiple occasions. This was confirmed by both a nurse and the Director of Nurses (DON), who acknowledged the potential danger of hypotension due to the resident's concurrent use of other antihypertensive medications and dialysis dependency. Two residents with end-stage renal disease and prescribed fluid restrictions were not managed according to their physician's orders. One resident's fluid intake was not accurately documented or communicated to the dietary department, resulting in excessive fluid being provided. The intake and output records were incomplete, and the dietary department was unaware of the fluid restriction. Similarly, another resident's fluid restriction was not consistently followed, with observations of excessive fluid at the bedside and incomplete documentation of fluid intake, indicating a lack of adherence to the prescribed fluid management plan. Additionally, the facility failed to rotate insulin injection sites for a resident with diabetes, as required to prevent complications such as lipohypertrophy. The medical records lacked documentation of injection sites, which was confirmed by the DON and a physician. Furthermore, a resident with a prescribed hand splint for hemiplegia was observed multiple times without the splint in place, and there was no documentation of refusal or inability to tolerate the splint, indicating non-compliance with the physician's orders for splint use.
Physician Order Signing Deficiency
Penalty
Summary
The facility failed to ensure that the physician signed and dated all orders for a resident, leading to a deficiency. The facility's policy requires physician orders and progress notes to be signed and dated every 30 days, or every 60 days after the first 90 days of a resident's admission. A resident, admitted in August 2016 with diagnoses including diabetes mellitus, chronic kidney disease, major depression with severe psychotic symptoms, and bipolar disorder, had their last physician-signed orders dated November 2024. No additional orders were signed by the physician after this date. During an interview, the Director of Nursing confirmed that the last signed physician's orders in the medical record were from November 2024, indicating non-compliance with the facility's policy.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents received timely visits from physicians or nurse practitioners as required by regulations. For one resident, the facility did not provide visits every 30 days during the first 90 days of admission. The resident, who was admitted with chronic kidney disease, end-stage renal disease, bipolar disorder, and generalized anxiety, had a gap of 61 days between visits. The medical records clerk and receptionist confirmed that no additional progress notes were available, indicating a lapse in the required oversight. Another resident, admitted in November 2020, experienced a significant lapse in physician visits, with a gap of 372 days between documented visits. Although the resident was seen by a nurse practitioner during this period, the facility did not meet the requirement for alternating visits between a physician and a nurse practitioner every 60 days. The Director of Nursing and the physician acknowledged the oversight and attempted to retrieve missing progress notes from the physician's office. A third resident, admitted in August 2016, had not been seen by a physician or nurse practitioner for 110 days, contrary to the requirement for visits every 60 days after the initial 90-day period. The Director of Nursing confirmed the absence of visit notes in the resident's medical record, indicating a failure to provide the necessary oversight and care. These deficiencies highlight lapses in the facility's adherence to regulatory requirements for resident care and oversight.
Consultant Pharmacist Fails to Identify Medication Irregularities
Penalty
Summary
The facility's Consultant Pharmacist failed to identify irregularities in medication administration during the monthly Medication Regimen Review (MRR) for two residents. For one resident, the pharmacist did not report the administration of Ultram, a pain medication, outside the prescribed pain level parameters. The resident was admitted with chronic pain syndrome and rheumatoid arthritis, and the medication was administered multiple times for pain levels below the prescribed threshold. Despite reviewing the medication administration records, the pharmacist did not document any recommendations or identify the discrepancy. For another resident, the pharmacist did not identify the lack of documented rationale for the ongoing use of a PRN psychotropic medication, Xanax. The resident, who had diagnoses including chronic kidney disease, bipolar disorder, and generalized anxiety, had been prescribed Xanax on a PRN basis for anxiety. However, there was no documentation supporting the necessity or effectiveness of the medication, nor was there a risk versus benefit rationale provided. The pharmacist assumed that the prescribers were aware of the requirement for documentation and did not review or ensure that the necessary documentation was in place. Interviews with the Consultant Pharmacist and the Director of Nursing revealed that the pharmacist did not consider it part of his role to ensure that prescribers documented the rationale for extending PRN psychotropic medications. The Director of Nursing expected the pharmacist to identify such issues and provide recommendations, but this did not occur. The pharmacist's oversight in both cases led to a failure in identifying and addressing medication irregularities, which were not communicated to the facility leadership as required.
Food Safety Deficiencies in Kitchen and Nourishment Areas
Penalty
Summary
The facility failed to adhere to professional standards of food safety, which could potentially lead to foodborne illness among residents. The surveyor observed multiple instances of improper labeling and dating of food products in the main kitchen's refrigerators. Specifically, trays of poured beverages and desserts were not labeled with the product name, preparation date, or use by date. Additionally, opened containers of thickened beverages were not labeled with the date they were opened or their use by date. The Food Service Director (FSD) confirmed that these items should have been labeled according to the facility's guidelines, which were not followed. Further deficiencies were noted in the storage practices within the walk-in freezer, where a large cardboard box containing frozen omelets was found open and unsealed, exposing the contents to potential contaminants. In the First Floor Unit nourishment kitchenette, several yogurts were found past their manufacturer's expiration date and were not disposed of as required. The FSD acknowledged that dietary staff are responsible for checking food expirations and confirmed that the expired yogurts should have been discarded. These lapses in food safety practices highlight the facility's failure to maintain proper food handling and storage protocols.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not self-administered without a physician's order and an assessment for self-administration for two residents. Resident #58, who was admitted with herpes viral keratitis, was observed with Prednisolone Ophthalmic Suspension on their overbed table and admitted to self-administering the medication nightly. Despite being cognitively intact and independently able to perform activities of daily living, there was no documented assessment or physician's order for self-administration, and the medication was not stored securely. Resident #73, admitted with post-polio syndrome, was observed with Fluticasone Nasal Spray on their overbed table. Although the resident expressed a desire to self-administer the nasal spray, there was no evaluation or physician's order for self-administration. The resident was dependent on staff for activities of daily living, and the medication was not stored securely. Interviews with facility staff, including nurses and the Director of Nursing, confirmed that the necessary assessments, teaching, and physician's orders were not completed for these residents to self-administer their medications. The facility's policies require that residents who wish to self-administer medications must have an assessment, teaching with return demonstration, and a physician's order, none of which were documented for these residents.
Resident Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident had their call light accessible and within reach, which is a requirement for residents to call for assistance. The resident, who was admitted in July 2014, had diagnoses including Alzheimer's disease, a history of falling, and anxiety, and required extensive assistance for activities of daily living due to a severe cognitive deficit. Observations made by the surveyor on multiple occasions revealed that the resident's call light was consistently out of reach, whether the resident was in bed or in a reclining wheelchair. The facility's policy on the resident call system mandates that residents should have the ability to contact staff for assistance from their bedside and from toilet and bathing areas. The resident's comprehensive care plan also specified that the call bell should be within reach while in the room, bathroom, or shower room. Interviews with staff, including CNAs and the Assistant Director of Nursing, confirmed that call lights should be within reach of residents at all times, regardless of their cognitive ability. Despite these policies and care plan interventions, the facility did not ensure compliance, resulting in the deficiency.
Failure to Notify Physician of Changes in Resident Condition
Penalty
Summary
The facility failed to notify the physician or responsible party of changes in condition for two residents, leading to deficiencies in care. For one resident, the facility did not communicate the results of a STAT chest x-ray to the physician, which was necessary for making a treatment decision. The resident had been started on an antibiotic for a possible urinary tract infection, and a subsequent fever led to the ordering of a chest x-ray and another antibiotic for possible pneumonia. The x-ray results, which showed clear lungs, were not reviewed by the facility staff until two days after they were sent, and there was no documentation indicating that the physician was informed of these results. Another resident, who was on a fluid restriction due to end-stage renal disease, was observed consuming fluids in excess of the prescribed limit. Despite multiple observations of non-compliance with the fluid restriction, there was no documentation that the attending physician group was notified. The resident was seen with various beverages at their bedside, and staff interviews confirmed that the resident was not compliant with the fluid restriction. The facility's policy required that the physician be notified of such non-compliance, but this was not done. The facility's failure to notify the physician of significant changes in the residents' conditions or non-compliance with treatment orders represents a breach of their own policies and regulatory standards. The lack of communication and documentation in these cases highlights deficiencies in the facility's processes for managing resident care and ensuring that physicians are informed of critical information necessary for making treatment decisions.
Unsecured Insulin Vial Left Unattended
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards on one of its units. During a medication administration process, a nurse left a vial of Lispro Insulin unattended on top of a medication cart. This occurred while the nurse was preparing the insulin for a resident with diabetes mellitus. The medication cart was left unlocked and unsupervised, with four residents in the immediate vicinity, which was against the facility's policy. The facility's policies on administering and storing medications clearly state that medication carts must be locked and inaccessible to residents when not under direct supervision. The nurse acknowledged leaving the insulin vial unattended and admitted that it should have been secured in the locked cart. The Unit Manager confirmed that medications must be secured in a locked cart when not directly supervised by the nurse.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, leading to deficiencies in care. Resident #30, who was admitted with chronic pain syndrome and rheumatoid arthritis, did not receive pain management consistent with professional standards. The resident was prescribed Ultram for severe pain levels between 7-10, but the medication was administered multiple times for pain levels below the prescribed parameters. Additionally, there was no comprehensive person-centered care plan developed to address the resident's pain management needs, which should have included both pharmacological and non-pharmacological interventions. Resident #57, admitted with a history of surgery on the digestive system and constipation, also experienced deficiencies in pain management. The resident was prescribed Hydromorphone for pain levels between 6-10, but the medication was administered six times for pain levels below the prescribed parameters. This administration was not in accordance with the physician's orders, indicating a failure to adhere to prescribed pain management protocols. Interviews with nursing staff, including Nurse #9, Unit Manager #1, and the Director of Nursing, confirmed that both residents received opioid medications outside of the prescribed pain level parameters. The staff acknowledged that pain medications should be administered as prescribed and within the specified pain level range. The lack of a comprehensive care plan for Resident #30 and the inappropriate administration of pain medication for both residents highlight significant deficiencies in the facility's pain management practices.
Concurrent Antibiotic Use Without Indication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication administration, specifically involving the concurrent use of two antibiotics, Augmentin and Bactrim, without adequate indications for their use. The resident, who had severe cognitive impairment and was diagnosed with gastroparesis and diabetes mellitus, was administered Augmentin based on a nurse practitioner's order before the results of a urinalysis confirmed a urinary tract infection. The resident's daughter had expressed concerns about a possible infection, leading to the initiation of the antibiotic treatment. Subsequently, the resident developed a fever, and a physician ordered a chest x-ray and prescribed Bactrim, suspecting aspiration pneumonia due to the resident's vomiting. However, the physician was not informed that the resident was already receiving Augmentin. The chest x-ray results, which showed clear lungs, were not reviewed by the facility staff until more than two days after they were sent, indicating a delay in communication and review of critical diagnostic information. Interviews with facility staff, including the nurse practitioner, physician, infection preventionist, and director of nursing, revealed a lack of communication and oversight in the administration of antibiotics. The infection preventionist noted that the resident did not meet the criteria for a urinary tract infection, and the director of nursing acknowledged that the resident should not have been on two antibiotics simultaneously without clinical indications. This deficiency highlights the need for improved communication and adherence to clinical guidelines in the administration of medications.
Failure to Monitor and Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary psychotropic medications. For one resident, the facility did not monitor for potential adverse consequences related to the use of an antianxiety medication, Buspirone. The resident, who had diagnoses including major depressive disorder and anxiety, was receiving Buspirone twice daily as per physician's orders. However, there was no documentation indicating that the facility was monitoring for side effects, which was confirmed during an interview with a unit manager. For another resident, the facility did not provide a documented rationale for the ongoing use of a PRN psychotropic benzodiazepine, Xanax. This resident had diagnoses including chronic kidney disease, end-stage renal disease, bipolar disorder, and generalized anxiety. Despite the resident's minimal use of Xanax and observations indicating calm behavior, the facility continued to extend the PRN order without proper documentation of necessity or effectiveness. Interviews with staff, including a nurse practitioner and the director of nurses, revealed that the rationale for the continued use of Xanax was not documented, and the medication was likely unnecessary. The facility's policies on psychotropic medication use and informed consent were not followed, as there was a lack of documentation supporting the necessity and benefit of the medications for the residents. The director of nurses acknowledged that the facility did not meet the standard for extending the psychotropic PRN medication, as the documentation was not resident-specific and did not include a complete rationale for continued use.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain an accurate and up-to-date medical record for a resident who was admitted in October 2024. During an interview, a nurse indicated that all physician and nurse practitioner (NP) progress notes are scanned into the electronic medical record under a miscellaneous tab. However, upon review, only one progress note was available since the resident's admission, dated November 27, 2024. The resident had a paid hospital leave but remained an active resident since admission. Interviews with the medical records clerk and the receptionist revealed that the process involves the receptionist receiving progress notes via email and then scanning them into the resident's record. The receptionist confirmed that no additional notes were available for the resident. An NP expressed surprise at the lack of notes and indicated a need to investigate further. Subsequent review of the medical record showed that additional notes were later added for November 2024, January 2025, and February 2025. The Director of Nurses acknowledged that all documents should have been included in the medical record at the time of the visits and suspected an issue with the physician's computer system.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Nurse #4 during a wound dressing change for Resident #72. The nurse did not perform hand hygiene after removing gloves and before donning new gloves, which is a critical step in preventing healthcare-associated infections. This lapse occurred multiple times during the procedure, including after cleansing the resident's G-tube site and sacral wound, and before applying new dressings and handling the resident's brief and linens. Resident #72, who was admitted to the facility in June 2024, had a stage 4 pressure ulcer in the sacral region and a gastrostomy tube due to dysphagia. The nurse admitted to not having hand sanitizer in the room and acknowledged the oversight when questioned by the surveyor. The Director of Nursing confirmed that staff are expected to perform hand hygiene between each glove change, highlighting a deviation from the facility's infection control policy.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by the inappropriate use of dual antibiotics for a resident who did not meet the criteria for a urinary tract infection (UTI) according to the facility's McGeer criteria. The resident, who had severe cognitive impairment, was treated with two antibiotics, Augmentin and Bactrim DS, despite only exhibiting one symptom and a positive urine culture, which did not fulfill the criteria for a UTI. The facility's policy requires that antibiotic usage be evaluated and practitioners be provided feedback, but this was not adhered to in this case. The resident's medical records indicated that they were started on Augmentin following a family request and a subsequent order from a nurse practitioner, despite the resident not meeting the infection criteria. The resident was later prescribed Bactrim DS by a physician who was unaware that the resident was already receiving Augmentin. This oversight led to the resident receiving two antibiotics simultaneously without proper verification of an infection or a review of the criteria with the clinicians, which violated the facility's antibiotic stewardship initiative. Interviews with the infection preventionist and the attending physician revealed that there was a lack of communication and monitoring regarding the resident's antibiotic treatment. The infection preventionist admitted to missing the review and notification process, which should have been conducted to ensure compliance with the facility's antibiotic stewardship program. The attending physician was not informed of the resident's ongoing treatment with Augmentin when ordering Bactrim DS, highlighting a breakdown in communication and oversight within the facility's infection control practices.
Inaccessible Survey Results for Residents
Penalty
Summary
The facility failed to ensure that statements of deficiencies and plans of correction from complaint investigations were prominently and readily accessible to residents, family members, and legal representatives without requiring them to ask to see them. During a resident group meeting, nine residents from the facility's three units reported being unaware of the availability of survey results and their ability to examine them independently. A surveyor's tour of the second-floor units and the lobby area revealed no postings of survey results. Instead, a binder labeled 'survey results' was found on a shelf behind the reception desk, inaccessible due to its location behind the desk and a table. The Administrator was unaware of the binder's location and its inaccessibility to residents and their representatives.
Failure to Notify State of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State agency regarding a change in the facility's Administrator. During an interview, the Administrator stated that he began his role on December 27, 2023. However, a review of the Health Care Facility Reporting System (HCFRS) indicated that the last notification to the State about an Administrator change was on October 30, 2023. Further examination of the HCFRS showed no record of the State Agency being informed of the current Administrator's appointment. The Director of Operations confirmed during an interview that the Administrator's information had not been updated since October 30, 2023, and mentioned that he believed the previous Director of Nursing had updated the information, which was not the case.
Failure to Notify Health Care Agent of Resident Incident
Penalty
Summary
The facility failed to immediately notify the Health Care Agent (HCA) of a resident who was found in a concerning situation. The resident, who had an activated Health Care Proxy and was on hospice care, was discovered lying fully clothed in a bathtub with cold water running and three inches of water surrounding them. Despite the facility's policy requiring prompt notification of significant changes in a resident's condition, the HCA was not informed until approximately six hours later by the hospice nurse. The incident occurred when a Certified Nurse Aide (CNA) found the resident in the bathtub and immediately informed a nurse. The nurse reported the incident to the Director of Nurses and the physician but failed to notify the HCA or the hospice agency. The physician was informed of the incident but was not made aware of the full details, including the resident being fully clothed and in cold water. The hospice nurse, upon learning of the incident later in the day, was the one who eventually notified the HCA. Interviews with facility staff, including the Assistant Director of Nurses (ADON) and the former Director of Nurses (DON), revealed that it was their expectation for nurses to immediately notify the HCA and hospice agency of any incidents. However, this protocol was not followed, resulting in a significant delay in communication with the resident's HCA, who expected to be informed right away. The resident's condition was noted to be concerning when the HCA visited later that day, prompting a request for hospital evaluation.
Failure to Assess and Document Vital Signs After Incident
Penalty
Summary
The facility failed to provide nursing services that met acceptable standards of practice for a resident who was found lying in a bathtub with three inches of cold water while fully clothed. The incident occurred at approximately 6:35 A.M., and the resident was observed to be visibly cold, shivering, and cold to the touch. Despite these observations, there was no documentation to indicate that a set of vital signs was obtained by the nursing staff immediately following the incident, which is inconsistent with the facility's policies on nursing examination, assessment, and documentation. The resident involved had a medical history that included Alzheimer's disease with late onset, psychotic disorder with delusions, muscle weakness, hypertensive heart disease with heart failure, type 2 diabetes mellitus with hyperglycemia, generalized anxiety disorder, and unspecified dementia with psychotic disturbance. The lack of immediate assessment and documentation of vital signs after the incident was a significant oversight, as vital signs are crucial indicators of a resident's health status and are necessary for appropriate medical evaluation and intervention. Interviews with the nursing staff, including Nurse #1 who was responsible for the resident's care at the time, revealed that there was no recollection or documentation of vital signs being taken after the incident. The Assistant Director of Nurses, the Physician, and the former Director of Nurses all expressed that it was their expectation for nurses to obtain and document vital signs as part of the nursing assessment following any incident, highlighting a deviation from standard nursing practice and facility policy.
Failure to Notify Hospice of Resident Incident
Penalty
Summary
The facility failed to ensure immediate communication with the hospice agency regarding a significant incident involving a resident under hospice care. On the morning of August 21, 2024, a resident was found by staff lying fully clothed in a bathtub with cold water running, surrounded by three inches of cold water. The resident was visibly cold, shivering, and cold to the touch. Despite the facility's policy requiring immediate notification of hospice staff in such situations, the hospice agency was not informed until six hours later when the hospice nurse arrived at the facility. The incident report and nurse progress notes lacked documentation of timely communication with the hospice agency. Interviews with facility staff, including nurses and the Assistant Director of Nurses, revealed a breakdown in communication and responsibility. Nurse #1, who discovered the resident, reported the incident to the Director of Nurses and the physician but did not notify the hospice agency. Nurse #3, who took over the resident's care, also failed to report the incident to hospice until the hospice nurse's arrival. The Assistant Director of Nurses and the former Director of Nurses both expressed that it was expected for nurses to immediately notify hospice of any incidents involving residents on hospice care.
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.
Illustrative
What surveyors actually found near you
We read the 542 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fall River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kimwell Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 13 | 0 |
| Fall River Jewish Home | 0.6 mi | ★★★★★ | 0 | 0 |
| Fall River Healthcare | 1.8 mi | ★★★★★ | 14 | 0 |
| Clifton Rehabilitation Nursing Center | 2.2 mi | ★★★★★ | 1 | 0 |
| Catholic Memorial Home | 2.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.