Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Mansion At Brigham during CMS and state inspections, most recent first.
Failure to Submit PBJ Staffing Data: The facility failed to electronically submit complete and accurate PBJ staffing data to CMS for an entire FY Q2 reporting period. The CASPER report showed no data submitted for the quarter and a one-star staffing rating. The DON, Regional Nurse Consultant, and Director of Operations all acknowledged the PBJ reporting issue and stated the expectation was that the data be submitted as required.
A resident with Alzheimer’s disease, severe cognitive impairment, and a stage 4 sacral pressure ulcer had an alternating pressure air mattress ordered and documented for use with checks each shift. Surveyors repeatedly observed the mattress control unit flashing an orange alert light across multiple shifts, including during care and medication administration, while staff still documented the mattress as functioning. Interviews showed staff knew a flashing signal meant a problem that needed attention, and the DON later observed the alert and found it stopped when the side tubes were pushed in.
A staff member left a pot boiling unattended on a gas stove, and a surveyor observed large flames coming from the burner with no staff in the kitchen nearby. The facility also failed to follow a high fall-risk resident’s care plan requiring supervision when out of bed; the resident had severe cognitive impairment, multiple unwitnessed falls from a wheelchair in the dining room, and was later observed in the dining room without staff present.
Meals were not consistently served at palatable temperatures, and residents reported concerns about food quality, limited variety, and running out of staple items like coffee, eggs, butter, and bread. Test trays showed hot items on both units ranging from warm to hot, with some foods such as potatoes described as hard and not hot enough, while cold items like milk and juice were above desired cold temperatures; staff also agreed some foods were not hot enough.
Failure to document and monitor a resident’s right hand skin tear: A resident with severe cognitive impairment and total dependence for care developed a skin tear on the right hand that was treated with steri-strips and a dressing after the NP was notified. The chart did not include a physician order for the treatment or daily monitoring, progress notes showed little ongoing wound documentation, and the DON stated there was no incident report and no order for dressing or shift monitoring.
Failure to Follow Catheter Bag Change Order: A resident with a suprapubic catheter and bladder dysfunction had a drainage bag order for weekly changes with dating/labeling, but the bag was observed unlabeled and undated and the TAR did not show routine changes for multiple months. Staff said the bag was changed only when the resident returned from urology, the order had been transcribed as PRN instead of routine, and no progress note documented the bag change.
Failure to obtain ordered weekly weights led to delayed recognition of a significant weight loss. A resident with COPD, AFib, weakness, and moderate cognitive impairment was admitted on a regular diet, later receiving Ensure BID and weight monitoring orders. The chart lacked documented weekly weights during the ordered period, and the resident lost 34 lbs, or 18.1%, over two months before the loss was identified by the RD.
The facility failed to complete annual CNA performance reviews for two of two eligible sampled CNAs. Survey review of employee records found no annual performance reviews, and the HR Director, DON, and Director of Operations all confirmed that annual reviews were expected but could not be located in the files.
Bed Gap Not Filled to Prevent Entrapment: A resident with intact cognition and dependence for bed mobility was repeatedly observed in bed with a large gap between the mattress and the footboard and no gap filler in place. The surveyor measured the gap at about six inches, and the bed/side rail assessment left the entrapment-spacing item blank. The DON said she had never seen a gap filler used at the foot of the bed, while the Maintenance Director and Administrator agreed a gap filler should be in place.
A resident experienced an unwitnessed fall, and the facility failed to notify the physician, health care agent, and administrative staff as required by policy. The nurse did not document the incident or inform the oncoming shift, leading to a delay in addressing the resident's injuries, which were later diagnosed as fractures. The DON was only informed after the family reported the fall.
A resident experienced an unwitnessed fall and was found on the floor by a nurse and CNA. The nurse did not document the fall, perform a thorough assessment, or notify the next shift, contrary to facility policy. The resident later complained of pain and was diagnosed with fractures at the hospital. The DON confirmed the nurse's failure to follow procedures.
The facility did not conduct, review, or document an annual facility-wide assessment to determine necessary resources for resident care during regular operations and emergencies. Despite policy requirements, the surveyor found that the facility could not provide a current assessment. Administrator #2, responsible for the assessment, admitted to not completing it and lacked access to previous assessments. The Director of Operations confirmed the oversight, leading to a deficiency.
The facility failed to provide a homelike dining experience, as residents were served meals using Styrofoam cups and bowls, plastic cutlery, and trays. This practice was due to staffing issues in the kitchen, preventing the use of regular dishes. Residents expressed dissatisfaction, and staff acknowledged the inappropriate use of disposable items.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in care. One resident lacked a fall care plan intervention, while another did not have personalized mood and behavior care plans. A third resident's care plan was incomplete for dialysis and antidepressant medication, and another resident's care plan lacked details on psychotropic medication use. Staff interviews revealed communication and implementation issues.
A facility failed to develop a care plan and ensure proper communication for a resident requiring dialysis. The resident, with end-stage kidney disease and moderately impaired cognition, lacked a documented physician's order for hemodialysis. The dialysis communication book, crucial for facility-dialysis center communication, was incomplete and not with the resident during sessions. Staff were unaware of the resident's dialysis access type, and there was no order to monitor the CVC site for infection.
The facility failed to maintain sufficient CNA staffing on weekends, leading to delays in resident care. Staffing records and interviews revealed that the facility was below the necessary CNA levels for multiple weekend shifts from April to September 2024. Despite efforts to hire more staff and change staffing agencies, challenges in maintaining adequate staffing persisted.
The facility failed to provide necessary substance abuse services for residents with a history of substance use disorder. A resident with a history of heroin and alcohol use was not offered AA/NA services despite expressing a desire to continue these meetings. Additionally, six other residents with similar histories were also not offered these services, contrary to the facility's policy.
The facility failed to ensure timely physician acknowledgment of pharmacist recommendations for two residents. One resident had an Ativan dose exceeding recommended levels without physician clarification, while another had a Zetia prescription without a documented diagnosis clarification. The Director of Nursing could not locate the relevant MMRs or physician responses, highlighting a lapse in communication and documentation.
The facility failed to secure medication rooms on two units, leaving them open and unattended, contrary to policy. A nurse admitted to leaving a medication room open after retrieving masks, acknowledging it was a mistake.
The facility did not maintain a current CLIA certificate, which expired and was not renewed, affecting the ability to perform necessary tests for residents requiring blood glucose monitoring. Additionally, a resident with dementia and other conditions did not have a required albumin level test performed, as the nursing staff failed to notify the lab service provider.
The facility failed to maintain adequate staffing in its dietary services, as observed by surveyors and reported by staff and residents. The facility assessment required three staff per shift, but observations showed only two staff were present on multiple occasions. A resident noted that meals were served on styrofoam dishes due to a lack of staff to wash dishes. The absence of a Food Service Director further exacerbated the staffing issues.
The facility failed to honor the food preferences of four residents, leading to dissatisfaction and unmet dietary needs. Residents reported receiving incorrect meal trays, missing preferred items, and not being involved in menu selection. Staff interviews revealed systemic issues with menu selection and communication between the kitchen and residents.
The facility failed to provide a nourishing evening snack when there was more than 14 hours between dinner and breakfast. The final food tray for the evening meal was passed at 5:25 P.M., and breakfast started at 7:30 A.M. the following day, resulting in a 14-hour and 45-minute gap. Residents reported limited snack options, and staff interviews confirmed that snacks were not consistently available. The Food Service Director and Dietician acknowledged the need for compliance with the policy, and the Administrator stated that meals should be served after 5:00 P.M. with substantial evening snacks available.
The facility failed to store food according to professional standards, with surveyors observing unlabeled and undated items in the refrigerator, freezer, and dry storage. Items were improperly stored, including food placed directly on the floor and open bags in the freezer. Dietary staff confirmed these practices were against policy.
The facility failed to maintain accurate medical records for four residents, including missing weight documentation for two residents, incorrect BiPAP usage records for another, and incomplete CNA service documentation. A resident's weights were not recorded in the EHR, and a broken BiPAP was falsely documented as in use. CNAs reported insufficient time for documentation due to workload, and a resident's weights were struck out in error without reweighing.
A resident with moderately impaired cognition and total dependence on staff for personal hygiene was observed with unwanted chin hair, which they expressed a desire to have removed. Despite the facility's policy on maintaining resident dignity, a CNA admitted to not having time to assist with the grooming, leading to a deficiency in care.
The facility failed to issue transfer notices and notify the Ombudsman for two residents transferred to the hospital. One resident with dementia was transferred due to low hematocrit and hemoglobin levels, while another resident with heart failure was transferred following a fall and admitted for hypokalemia and congestive heart failure. The facility did not document the required notifications.
The facility failed to provide a bed hold policy to two residents before hospital transfers. One resident with dementia was transferred due to low hematocrit and hemoglobin levels, while another cognitively intact resident was transferred after a fall and diagnosis of hypokalemia and heart failure. The facility did not issue the required bed hold policy to either resident or their representatives.
A facility failed to complete a timely PASRR for a resident with SMI after their stay exceeded the 30-day exemption period. The resident was admitted with bipolar disorder and depression, and although initially screened, a subsequent Level I Screening was not submitted as required. The Admissions Liaison and Social Worker indicated a lack of responsibility and access to the PASRR portal, and the Administrator was unaware of the oversight.
The facility failed to create baseline care plans within 48 hours of admission for three residents, including one with end-stage kidney disease and another with PTSD and diabetes. The absence of these plans, which are crucial for effective and person-centered care, was confirmed by nursing staff and the Director of Nursing.
The facility failed to review and revise comprehensive care plans for two residents following assessments. One resident's care plan was not updated to reflect a change in advanced directives to DNR, and another resident's care plan lacked specific details about high-risk medication use. Staffing issues and lack of coordination contributed to these deficiencies.
A resident with severe cognitive impairment was found to have an air mattress set incorrectly, contrary to the physician's orders. The physician had specified a setting of 130, but observations showed it was set to 150. Interviews with staff revealed a lack of adherence to the physician's orders and manufacturer guidelines, despite the facility's policy requiring compliance with such orders.
A resident with limited range of motion in the left hand did not receive appropriate care as the facility failed to implement a splint-wearing schedule. Despite recommendations from the occupational therapist, nursing staff were unaware of the requirement, and the resident was observed multiple times without the prescribed splint. This indicates a lack of communication and documentation regarding the resident's care plan.
A facility failed to document the size of a resident's indwelling urinary catheter in the physician's orders, leading to a deficiency in care. The resident, admitted with urine retention, experienced discomfort and discharge, prompting catheter irrigation. The omission was confirmed through record reviews and staff interviews, with the catheter size eventually identified as 16 French with a 10-milliliter balloon.
A resident with severe cognitive impairment and significant weight loss did not receive prescribed fortified foods and nutritional supplements. Despite physician orders and care plans, the resident's meal trays consistently lacked fortified items such as shakes, juices, and yogurt. Staff interviews confirmed the absence of these items, contributing to the resident's continued weight loss.
A facility failed to follow professional standards for enteral feeding administration for a resident with dysphagia and hemiplegia. The resident's Jevity 1.2 bottle, dated several days prior, was used beyond the manufacturer's recommended hang time. Staff interviews revealed that the nursing staff did not change the bottle daily as required, leading to the deficiency.
The facility failed to provide necessary respiratory care for two residents. One resident's BiPAP machine was broken and not repaired, despite staff awareness and a physician's order for its use. Another resident received oxygen at a higher rate than prescribed, with staff unaware of the correct settings. These deficiencies highlight a lack of adherence to care plans and physician's orders.
A facility failed to develop a comprehensive trauma-informed care plan for a resident with PTSD. The care plan lacked specific triggers and interventions, contrary to the facility's policy. Interviews with the DON and MDS Nurse confirmed the deficiency, highlighting the need for resident-specific care plans.
A facility failed to specify the duration for a PRN antipsychotic medication prescribed to a resident with borderline personality disorder and other conditions. The facility's policy requires PRN psychotropic drugs to have a limited duration, typically 14 days, unless extended with documented rationale. Despite a recommendation from the Psychiatric Nurse Practitioner to discontinue the PRN Zyprexa, the facility did not address this within the expected timeframe, resulting in a deficiency.
A resident with dysphagia and hemiplegia was not provided with the physician-ordered therapeutic diet. Despite orders for a regular diet with dysphagia advanced texture and thin liquids, the resident received a meal that did not meet these specifications. Dietary staff were preparing meals based on memory due to a recent change in food vendors and lack of updated diet breakdowns. The facility's dietary department failed to adhere to the prescribed diet, as confirmed by the Food Service Director and other staff.
A resident with severe cognitive impairment and dysphagia was not consistently provided with a lip plate during meals, despite a physician's order and facility policy requiring it. Observations showed the resident was served breakfast without the necessary adaptive equipment, and staff interviews confirmed the kitchen's responsibility to supply it.
The facility did not notify the State Agency of a change in its Administrator. Administrator #2 was noted as the current Administrator as of June 21, 2024, but Administrator #1 began on September 9, 2024, without the State Agency being informed. Administrator #2 confirmed her last day was September 6, 2024, and the Chief Nursing Officer admitted the oversight.
The facility did not provide accurate estimated costs on Advanced Beneficiary Notices (ABNs) for two residents who transitioned off Medicare Part-A benefits. The ABNs lacked a detailed cost breakdown, which is essential for informing residents of their potential financial liabilities for services not covered by Medicare. Interviews with the Business Office Manager and Administrator confirmed the omission.
A facility failed to encode and transmit a Minimum Data Set (MDS) discharge assessment for a resident in a timely manner. The resident, admitted with pancreatitis and skin cancer, was discharged home, but the required MDS discharge assessment was not completed within the mandated 14 days. Interviews with the DON and MDS Nurse confirmed the oversight.
The facility inaccurately coded the MDS for two residents, leading to deficiencies in their assessments. One resident's MDS incorrectly indicated the use of anticoagulant and antiplatelet medications, while another resident's discharge location was wrongly coded. These errors were confirmed by the MDS Nurse and reflect a failure in ensuring accurate resident assessments.
The facility failed to post daily nurse staffing information as required by its policy. Observations on multiple days showed the absence of this information in the reception area. The Scheduler admitted to not posting the information on certain days, including weekends, due to lack of assigned responsibility. The DON confirmed the requirement for daily posting, indicating a lapse in compliance.
The facility failed to ensure that the kitchen staff consistently followed the established weekly menu for resident meals. Observations revealed that meals served did not match the planned menu, with missing ingredients and unplanned substitutions. Staff interviews indicated issues with a cook not adhering to the menu, leading to deviations. A resident reported being served random food not on the menu and often having no alternate meal choice.
The facility failed to serve food and beverages at safe and appetizing temperatures, as required by their policies. A test tray observation revealed that food items were not within acceptable temperature ranges, with a cold tuna sandwich served at 69.1°F and mixed vegetables at 106.9°F. The facility's records showed inconsistent measurement and recording of food temperatures, and residents expressed dissatisfaction with the food quality. Staff admitted to not measuring food temperatures due to being too busy, and there was insufficient food prepared for test trays.
The Facility failed to maintain accurate medical records for two residents, as weekly skin assessments were not consistently documented. One resident's records lacked documentation for several weeks, while another's records showed scheduled checks marked as completed without corresponding assessment forms. The DON confirmed the requirement for weekly documentation.
A resident under hospice care passed away, but the facility failed to notify the Health Care Agent (HCA) and Hospice Agency in a timely manner. The delay occurred because the former DON did not promptly pronounce the death, and the LPN on duty was unable to do so. The HCA and Hospice Agency were informed approximately eight hours later when a family member arrived at the facility.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the entire FY Quarter 2 2025 reporting period, January 1 through March 31, based on payroll and other verifiable and auditable data. Review of the PBJ Staffing Report, CASPER Report 1705D, showed the facility triggered for failing to submit data for the quarter and for receiving a one-star staffing rating. During interviews, the DON stated she was not responsible for PBJ reporting but expected the facility to submit it as required. The Regional Nurse Consultant acknowledged awareness of the PBJ reporting concerns and stated the expectation was that the data be submitted as required. The Director of Operations stated the PBJ staffing had not been submitted for the quarter and had since been submitted as required.
Flashing Air Mattress Alert Not Addressed for Resident With Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that an intervention used to prevent and manage a pressure ulcer was effectively implemented for one resident with a stage 4 sacral pressure ulcer. The resident had diagnoses including Alzheimer’s disease, severe cognitive impairment with a Brief Interview for Mental Status score of 0 out of 15, and dependence on staff for all aspects of daily care. Physician orders and the care plan directed use of an alternating pressure air mattress, with staff to check placement, setting, and function every shift. During multiple observations, the air mattress control unit on the resident’s bed was seen flashing an orange alert indicator with a triangle and exclamation point symbol. This was observed on the afternoon of 9/15/25 and repeatedly on 9/16/25 during the morning, medication pass, breakfast, and later in the day while the resident was in bed or sitting up. The alert remained illuminated and flashing across different shifts, including when a nurse administered medication and documented on the TAR that the mattress was functioning. Interviews confirmed that staff understood a flashing light meant there was a problem that needed to be addressed. A CNA stated the resident stayed up only a short time because of the wound and would be returned to bed before the end of the shift. A nurse said the flashing signal meant the mattress had something wrong with it and needed to be addressed, and that any staff entering the room should alert the nurse if the signal was flashing. The DON stated that a flashing light meant there was a problem, and when she and the surveyor observed it, pushing in the side tubes stopped the flashing. The DON also stated staff should have noticed the flashing light and informed her.
Unattended Cooking and Failure to Supervise High Fall-Risk Resident
Penalty
Summary
The facility failed to keep the kitchen environment free of accident hazards when a staff member left a large double pot boiling over two gas burners unattended. On 9/15/25 at 6:48 A.M., a surveyor observed a large rectangle hotel pan on the gas stove covering the front and back burners, with a pot of vigorously boiling water inside and large flames coming from the back gas burner, extending approximately 12 inches vertically. No staff were present in the kitchen or nearby hallway. At 6:54 A.M., the staff member returned, turned off the burner, and stated the pot had been on for about 20 minutes and contained eggs; he/she said the kitchen should not have been left unattended in that condition. The Food Service Director and Regional Food Service Director later stated that food should never be left cooking unattended and that the double boiler should not have been unattended, noting staff had recently received fire safety in-service training. The facility also failed to follow the care plan for a resident with severe cognitive impairment and high fall risk. The resident was admitted in June 2025 with diagnoses including dementia, pneumonia, and hypertension, and the most recent MDS showed a BIMS score of 1 out of 15. The resident’s care plan identified high fall risk related to advanced dementia, poor safety awareness, and poor balance, and included an intervention to keep the resident in a supervised area with increased supervision in common areas when out of bed. The Kardex also directed staff to keep the resident in supervised areas and common areas for increased supervision when out of bed. Despite these interventions, the resident had multiple unwitnessed falls from a wheelchair in the dining room on 7/13/25, 7/15/25, and 7/19/25. Records showed the resident was found on the floor after each incident, with staff documenting no apparent injuries and normal neurological checks. During observation on 9/16/25 at 10:00 A.M., the resident was seen in a wheelchair in the dining room with no staff present to supervise residents. Staff interviews indicated the resident should have been supervised whenever out of bed, and one nurse stated there should always be a staff member in the dining room supervising residents there. The DON agreed the care plan should be followed and stated that the resident was not being supervised when in the wheelchair.
Meals Not Served at Consistent Palatable Temperatures
Penalty
Summary
Food and drink were not consistently prepared and served at palatable, appetizing temperatures on two units. During resident screening and a resident group, multiple residents reported concerns about meals, including not having enough food, running out of staple items such as coffee, eggs, butter, and bread, meals not matching ordered diets, limited variety, and hot foods that were not always hot. Residents also described the food in general as not good and said meals were sometimes cold. Test tray observations on the lunch meal showed mixed temperatures and food quality concerns. On one unit, hot items such as pureed cream corn, marinated chicken thighs, roasted potatoes, dysphagia advanced potatoes, corn, gravy, ground chicken, mashed potatoes, puree chicken, and puree corn were recorded at temperatures ranging from 154.2 to 179.8 degrees Fahrenheit, while milk and apple juice were 42.6 and 43.5 degrees Fahrenheit. On the second unit, a test tray delivered from the kitchen contained marinated chicken thighs at 109 degrees Fahrenheit, roasted potatoes at 109 degrees Fahrenheit, corn at 113 degrees Fahrenheit, and apple juice at 53 degrees Fahrenheit; staff present said the food was not hot enough. On the first-floor unit, the test tray included marinated chicken thighs at 142 degrees Fahrenheit, roasted potatoes at 113 degrees Fahrenheit with a hard texture, corn at 116 degrees Fahrenheit, milk at 48.3 degrees Fahrenheit, and coffee at 167.2 degrees Fahrenheit. During dining room observation, four residents at one table had not eaten any of their potatoes and had large amounts of uneaten food remaining on their plates.
Failure to Document and Monitor a Resident’s Right Hand Skin Tear
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided for a skin tear on the back of a resident’s right hand. The resident was admitted in June 2020 and had diagnoses including Alzheimer’s disease and a stage 4 sacral pressure ulcer. The most recent MDS indicated severe cognitive impairment, with a score of 0 out of 15 on the Brief Interview for Mental Status, and the resident was dependent on staff for all aspects of daily care. During survey observations, the resident was in bed and unable to participate in an interview, and the back of the right hand had several steri-strips covering dark discolored skin; later observations showed the steri-strips curled on the edges with dark red or dark discolored skin visible underneath. The clinical record showed that a CNA discovered the skin tear and the NP ordered cleansing with NS, approximation of the wound edges with steri-strips, and a dressing with daily monitoring. However, the physician’s orders, MAR, and TAR did not include an order for treatment or monitoring of the right hand injury. Progress notes documented the wound on 8/31/25 and 9/14/25, but the record otherwise did not show ongoing monitoring of the skin tear from 8/26/25 through 9/16/25. Staff interviews indicated that new skin tears should prompt physician notification, orders for care and treatment, family notification, and an incident report, and the DON stated there was no incident report for the injury and no physician’s order for the dressing or for monitoring the skin tear each shift.
Failure to Follow Catheter Bag Change Order
Penalty
Summary
The facility failed to ensure professional standards of practice for care of a suprapubic urinary catheter for one resident with neuromuscular dysfunction of the bladder and an indwelling catheter. The resident’s active physician order dated 3/20/25 directed staff to change the catheter bag weekly and label it with the date, but the resident was observed with an unlabeled and undated drainage bag hanging on the bedframe, and the treatment record did not show catheter bag changes for July, August, or September 2025. During interview, the resident stated the catheter drainage bag was changed only once a month when returning from urology appointments and not weekly. A nurse stated catheter care includes changing the drainage bag weekly and as needed, documenting the task in the TAR, and following up with a progress note, but also said the bag was changed on 9/15/25 even though the order was not scheduled routinely. Review of the MAR/TAR with the nurse showed the order had been transcribed as as needed rather than routinely scheduled, and the medical record did not contain a progress note documenting the bag change. The DON stated drainage bags are supposed to be changed weekly and physician orders should be carried out.
Failure to Obtain Ordered Weekly Weights and Detect Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for one resident by not obtaining weekly weights as ordered and by not identifying a significant weight loss in a timely manner. The resident was admitted with diagnoses including COPD, chronic atrial fibrillation, and weakness, and the MDS showed moderate cognitive impairment with a BIMS score of 8 out of 15. The facility’s weight assessment policy required admission weights, weekly weights for two weeks, and confirmation/review of significant weight changes, but the resident’s record did not show weights being obtained during the ordered weekly monitoring period. The resident’s weight record showed 188 lbs on admission, then 154.0 lbs on 7/31/25, 153.5 lbs on 8/6/25, 157.8 lbs on 8/12/25, 153.7 lbs on 8/19/25, and 154.2 lbs on 9/13/25. The medical record showed a loss of 34 lbs from 5/30/25 to 7/31/25, equal to an 18.1% weight loss over two months. The record did not show any weights obtained between 5/30/25 and 7/31/25, and the June 2025 TAR did not document any weights for the month. The record also did not show that the resident refused weights. The resident had physician orders for a regular diet and later Ensure twice daily, along with weekly weights and then monthly weights. The RD documented on admission that the resident had stable weight and fair appetite, but later noted a significant 30-lb weight loss over two months and that weekly weights and monitoring were needed. The RD and DON both stated that newly admitted residents are weighed on admission and then weekly for four weeks, and the RD said the resident’s weight loss would have been detected sooner if the weekly weights had been completed.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for two of two eligible sampled CNAs. During review of three CNA employee records, the surveyor was unable to locate annual performance reviews for the two eligible CNAs. In interviews, the Regional Human Resources Director, who was covering for the facility in the absence of an HR director, reviewed the employee files and stated that CNAs should receive an annual performance review, then later said she could not locate any performance reviews and felt they had not been completed. The Director of Nursing stated she had been in the facility for three months and that performance reviews should be completed annually, and the Director of Operations stated that the facility expectation was that annual performance reviews are completed.
Bed Gap Not Filled to Prevent Entrapment
Penalty
Summary
The facility failed to ensure that a gap in the bed was filled to prevent possible entrapment for Resident #42. The resident was admitted in July 2024 with diagnoses including congestive heart failure and lower back pain. The most recent MDS, dated 9/3/25, indicated a BIMS score of 15 out of 15, showing intact cognition, and also indicated the resident was dependent on staff for rolling from side to side and returning to the back-lying position. During multiple observations on 9/15/25, 9/16/25, and 9/17/25, the surveyor saw Resident #42 in bed with a large gap between the mattress and the footboard and no gap filler in place. The surveyor measured the gap at approximately six inches. The facility’s Bed/Side rail assessment, dated 5/30/25, left blank the item addressing whether spacings between the bed rail, mattress, and bed surround were appropriate to prevent entrapment. During interviews, the DON stated she had never seen a gap filler used at the foot of the bed, while the Maintenance Director and Administrator agreed that a gap filler should be in place due to the gap.
Failure to Report and Document Resident Fall
Penalty
Summary
The facility failed to adhere to its policies regarding the notification of changes and fall prevention for a resident who experienced an unwitnessed fall during the overnight shift. The resident, who had a medical history including congestive heart failure and muscle weakness, was found sitting on the floor by a nurse and a CNA. Despite the facility's policy requiring immediate notification of the resident's physician, health care agent, and administrative staff in such incidents, the nurse did not report the fall to any of these parties. The nurse, who was aware of the facility's policies, assessed the resident and found no immediate signs of injury. However, the nurse did not document the incident, notify the oncoming shift nurse, or complete an incident report. The resident later complained of back pain, leading to a hospital transfer where fractures were diagnosed. The lack of documentation and communication resulted in a delay in addressing the resident's injuries. The Director of Nurses was not informed of the fall until the resident's family reported it the following day. An investigation revealed that the nurse had not followed the required procedures, including documenting the incident and notifying relevant parties. The nurse later admitted to forgetting to report and document the fall, which was only addressed after the DON initiated an investigation.
Failure to Document and Assess After Resident Fall
Penalty
Summary
The facility failed to provide nursing care and treatment that met professional standards of quality for a resident who experienced an unwitnessed fall. During the overnight shift, the resident was found sitting on the floor by a nurse and a CNA after a fall. Although the nurse claimed to have assessed the resident before moving them, there was no documentation to support that an adequate assessment was conducted for potential injuries. The following day, the resident complained of pain and was diagnosed with fractures after being transferred to the hospital. The facility's policies required a comprehensive post-fall assessment, documentation, and notification of the physician and family, none of which were completed by the nurse on duty. The nurse did not document the fall, perform neurological checks, or report the incident to the next shift. The nurse was aware of the facility's policies but failed to adhere to them, resulting in a lack of immediate and appropriate care for the resident. The Director of Nursing was not informed of the fall until the resident's family raised concerns the next day. Upon assessment, the resident was found to be in pain and was subsequently sent to the hospital. The DON confirmed that the nurse did not follow the facility's procedures and policies, which included assessing the resident for injuries, documenting the incident, and notifying the appropriate parties.
Failure to Conduct Annual Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct, review, and document a facility-wide assessment annually to determine the necessary resources for competent resident care during both regular operations and emergencies. The facility's policy, dated 3/4/24, mandates an annual assessment to establish responsibilities and procedures for the assessment process. However, during a survey, the facility was unable to provide a current assessment. The surveyor requested the assessment on two occasions, but Administrator #1 could only provide an outdated version and was unable to locate any other assessments. Administrator #2, who had been employed for about 10 weeks, admitted to not conducting the required assessment review and lacked access to previous assessments. The Director of Operations acknowledged that Administrator #2 was responsible for updating the assessment but failed to do so. The facility's policy requires the assessment to be updated annually and whenever there are significant changes, but this was not adhered to, resulting in a deficiency.
Failure to Provide Homelike Dining Experience
Penalty
Summary
The facility failed to ensure a homelike dining experience for residents on two units, as observed by surveyors. During multiple observations, residents were served meals using Styrofoam cups and bowls, plastic cutlery, and trays, which did not align with the facility's policy of promoting and maintaining resident dignity during mealtimes. The use of disposable items was consistent across both breakfast and lunch services on different days, affecting all observed residents in the dining areas. Interviews with residents and staff revealed dissatisfaction with the use of Styrofoam and plastic items, with residents expressing a desire for meals to be served on actual dishes rather than trays. Staff interviews indicated that the use of disposable items was due to staffing issues in the kitchen, which prevented the washing of regular dishes. The Food Service Director and the facility Administrator acknowledged that the use of paper and Styrofoam products was not appropriate and that meals should not be served on trays in the dining rooms.
Deficiencies in Comprehensive Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in their care. For one resident, the facility did not implement a fall care plan intervention to keep a urinal within reach and failed to develop a fall care plan intervention for fall mats. Observations showed that the fall mat was not properly positioned, and the urinal was not visible in the resident's room. Interviews with staff revealed inconsistencies in the communication and implementation of care plan interventions, with some staff unaware of the need for fall mats or the urinal. Another resident with a history of borderline personality disorder, suicidal ideations, major depression disorder, and opioid abuse did not have personalized mood, behavior, and substance abuse care plans. The resident's care plan failed to address their history of homicidal ideation, opiate and marijuana abuse, and feces smearing behavior. Interviews with the social worker confirmed the need for personalized care plans to address these issues. Additionally, a resident with end-stage kidney disease did not have a comprehensive care plan for dialysis and antidepressant medication. The care plan lacked details on dialysis schedules and care for the dialysis access site. Another resident with PTSD and hemiplegia did not have a care plan for psychotropic medication use, missing specific medication details and potential side effects. Interviews with the Director of Nursing confirmed the absence of these critical care plan components.
Failure in Dialysis Care and Communication
Penalty
Summary
The facility failed to develop a comprehensive plan of care for a resident requiring dialysis and did not ensure proper communication between the nursing facility and the dialysis center. The resident, who was admitted with end-stage kidney disease, pneumonia, and a fracture, had moderately impaired cognition and required moderate assistance with daily activities. Despite these needs, the facility did not have a physician's order for hemodialysis documented in the resident's records for September 2024. Additionally, the dialysis communication book, which is essential for conveying needs, changes, and concerns between the facility and the dialysis center, contained only three dated communication forms out of a possible twelve. On the day of the survey, it was observed that the dialysis communication book was not with the resident as required, indicating a lapse in the communication process. Nurse #4 acknowledged that the book should accompany the resident to dialysis sessions, which occur three times a week. Furthermore, Nurse #4 was unaware of the type of dialysis access the resident had, while Nurse #6 later confirmed the resident had a Central Venous Catheter (CVC) for dialysis access. Nurse #6 also noted the absence of a physician's order to monitor the CVC site for infection and drainage, highlighting a significant oversight in the resident's care plan.
Facility Fails to Maintain Adequate Weekend CNA Staffing
Penalty
Summary
The facility failed to maintain sufficient nursing staff to ensure resident safety and well-being, particularly on weekends. The deficiency was identified through a review of staffing records and interviews with residents and staff. Residents expressed concerns about the lack of certified nurse assistants (CNAs), leading to delays in responding to call lights. The Chief Nursing Officer (CNO) confirmed that the facility did not have a formal assessment of staffing needs, but provided a list of necessary staffing levels, which were not met on multiple occasions. The CASPER Payroll-Based Journal (PBJ) Staffing Data Report for fiscal year Quarter 3, 2024, indicated excessively low weekend staffing. The facility's weekend staff schedules from April to June 2024 showed that the facility was below the determined minimum CNA staffing levels for 20 weekend shifts. This issue persisted into the next quarter, with 16 additional weekend shifts lacking sufficient CNA staff. Interviews with CNAs and nurses revealed that the staffing shortages were particularly severe during April to June 2024, and although there were improvements after changing staffing agencies, challenges remained. The Director of Nursing (DON) acknowledged the staffing deficiencies during the specified quarter and noted efforts to hire more staff and change staffing agencies. Despite these efforts, the facility continued to struggle with maintaining adequate CNA staffing levels. The scheduler confirmed that the staffing ratios provided by the CNO were accurate and that the facility had difficulty replacing call-outs or finding enough CNAs to meet the minimum staffing requirements.
Failure to Provide Substance Abuse Services
Penalty
Summary
The facility failed to provide necessary substance abuse services for residents with a history of substance use disorder. Specifically, Resident #47, who was admitted with diagnoses including bipolar disorder, PTSD, and borderline personality disorder, was not offered Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) services despite having a history of heroin and alcohol use. The resident expressed a desire to continue participating in AA/NA meetings, which they had attended in the community prior to admission, but reported that no such services were offered by the facility until the day of the interview. Additionally, the facility's social worker identified six other residents with histories of alcohol, narcotics, and marijuana use who also had not been offered AA/NA services. The facility's policy on 'Safety for Residents with Substance Abuse Disorder' indicates that efforts should be made to prevent substance use, including providing treatment services such as behavioral health services and AA/NA meetings. However, the facility did not adhere to this policy, resulting in a deficiency in providing necessary behavioral health care and services to residents with substance use disorders.
Failure to Address Pharmacist Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two residents. Resident #33, who was admitted with diagnoses including dementia and anxiety, had a doctor's order for Ativan 5 mg PRN, which exceeded the recommended initial dose for the elderly. The MMR requested clarification of the Ativan dose, but the medical record did not indicate that the doctor was made aware of this recommendation or that a response was provided. Resident #47, admitted with diagnoses including PTSD, hemiplegia, and diabetes, had a doctor's order for Zetia 10 mg for diabetes. The MMR requested clarification of the diagnosis for the use of Zetia, but there was no documentation of the physician's response. During an interview, the Director of Nursing stated that the pharmacist reviewed all residents on the specified date but was unable to locate any of the MMRs or physician responses, indicating a lapse in communication and documentation processes.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional standards of practice. Specifically, the medication rooms on both the first and second floors were observed to be open and unattended by staff. On two separate occasions, the surveyor noted that the medication rooms were left open without any staff present within eyesight, which is contrary to the facility's policy that requires all drugs and biologicals to be stored in locked compartments with access limited to authorized personnel. During an interview, a nurse admitted to leaving the medication room open after retrieving masks, acknowledging it was a mistake and that the door should never be left open.
Failure to Maintain CLIA Certificate and Obtain Required Lab Test
Penalty
Summary
The facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility. During the survey, it was discovered that the facility's CLIA certificate had expired, and the payment for renewal was overdue. The Administrator acknowledged the lapse, and the Regional Nurse confirmed that the certificate should have been renewed, especially since there were seven residents requiring blood glucose monitoring, which necessitates a valid CLIA certificate. Additionally, the facility failed to obtain a necessary laboratory test for a resident. The resident, who was admitted with diagnoses including dementia, dysphagia, and osteoarthritis, had a physician's order to check an albumin level on the next lab day. However, the results were not found in the resident's electronic or paper medical records. The Director of Nursing and the Regional Nurse confirmed that the albumin level was not obtained as required, and the nursing staff failed to notify the laboratory service provider to perform the test.
Insufficient Staffing in Dietary Services
Penalty
Summary
The facility failed to provide sufficient staff to effectively carry out the functions of the food and nutrition services, as observed and reported by both staff and residents. The facility assessment indicated a requirement of 270 hours for dietary services, yet observations on multiple occasions showed that the kitchen was understaffed. On several days, only two staff members were present instead of the required three, as confirmed by interviews with dietary staff and the Food Services Director. The absence of a Food Service Director further compounded the staffing issues, as the newly hired director was still in orientation. During a Resident Council meeting, a resident reported that due to insufficient staff, meals were served on styrofoam dishes because there were not enough personnel to wash dishes. Interviews with the Regional Nurse and the Administrator confirmed that the kitchen should be staffed with three individuals per shift, including two dietary staff and one cook. The Administrator also clarified that the facility assessment hours were divided into 120 hours for cooks and 150 hours for dietary staff, excluding the Food Services Director's 40 hours.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of four residents, leading to dissatisfaction and unmet dietary needs. Resident #17, who has severe cognitive impairment and requires a mechanically altered diet, was repeatedly served eggs despite having a documented dislike for them. Staff interviews confirmed that the resident's preferences were known but not honored, and the kitchen staff failed to follow the diet slip instructions. Resident #14, who is cognitively intact, expressed frustration over consistently receiving incorrect meal trays. Despite multiple complaints, the resident's preferences for breakfast items like oatmeal and coffee were not met, and the resident was served disliked items such as eggs. The resident also reported not being involved in menu planning and not receiving alternative meal options when requested. Resident #2, also cognitively intact, did not receive requested items like bananas and yogurt, which were important for their dietary needs. The resident was served ham, a disliked item, and expressed concern over the lack of menu selection opportunities. Similarly, Resident #10 reported consistently receiving incorrect meal trays, missing items like bananas and yogurt, and not being involved in menu selection. Staff interviews revealed systemic issues with menu selection and communication between the kitchen and residents, leading to unmet food preferences.
Failure to Provide Nourishing Evening Snacks
Penalty
Summary
The facility failed to provide a nourishing evening snack when there was more than 14 hours between dinner and breakfast, as observed by surveyors. The facility's policy requires that no more than 14 hours should elapse between the evening meal and breakfast unless a nourishing snack is provided at bedtime. However, the surveyor noted that the final food tray for the evening meal was passed at 5:25 P.M., and breakfast started at 7:30 A.M. the following day, resulting in a 14-hour and 45-minute gap. Residents reported that they sometimes received an evening snack upon request, but there were limited options, and certain items like sandwiches and peanut butter were unavailable. Interviews with staff and residents revealed that the snack options were insufficient and not consistently available. Residents expressed dissatisfaction with the lack of snack choices, and the Food Service Director acknowledged the need to adjust meal times to comply with the policy. The Dietician confirmed that substantial evening snacks should be available when the time between dinner and breakfast exceeds 14 hours. The Administrator also stated that meals should be served after 5:00 P.M., and substantial evening snacks should be available on the units.
Deficiencies in Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage, as observed by surveyors. In the refrigerator, several items such as heads of lettuce, tomatoes, cabbages, and various leftovers were found without labels or dates. Additionally, a water jug with sliced lemons was also not labeled or dated. These items were improperly stored, with some placed directly on shelves or on top of other containers, contrary to the facility's policy that requires labeling with the delivery date and proper storage. In the dry food storage area, multiple food items, including packs of ginger ale, boxes of frozen bread, dinner rolls, canned goods, and ground coffee, were found stored directly on the floor, violating the policy that mandates storage at least six inches off the ground. In the freezer, open bags of frozen French toast, steak fries, and cookie dough were also found without labels or dates. Dietary staff acknowledged these deficiencies, noting that unlabeled and undated food should be discarded, and that food should not be stored on the floor or left in open bags.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents, leading to several deficiencies. For Resident #22, the facility did not document weights in the Electronic Health Record (EHR) as required by the physician's order. Although the Certified Nurse Assistant (CNA) reported the weights verbally to the nurse, there was no documentation in the EHR, which was confirmed by interviews with the CNA, Nurse #2, and the Regional Nurse. Resident #2's medical record inaccurately documented the use of a BiPAP machine, which was broken and not in use. Despite the resident's report of the broken BiPAP and the nurse's acknowledgment of the issue, the Treatment Administration Record (TAR) falsely indicated that the BiPAP was implemented on several shifts. The Director of Nursing (DON) was aware of the broken BiPAP but did not ensure the plan of care was updated or changed. For Resident #28, the facility failed to document services provided by CNAs for the majority of shifts in August 2024. The Director of Nursing confirmed the expectation for CNAs to document services each shift, but CNA #3 reported insufficient time to complete documentation due to workload. Additionally, Resident #23's weights were not documented in the medical record, and several weights were struck out in error without reweighing the resident. The Dietician confirmed the lack of documented weights since admission, despite the resident's history of refusing weights.
Failure to Assist Resident with Personal Grooming
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity by not providing assistance with the removal of unwanted chin hair. The resident, who was admitted in March 2021 with diagnoses including heart disease, kidney disease, and depression, expressed a desire to have the chin hair removed. The Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and was totally dependent on staff for personal hygiene. Despite this, the section of the MDS indicating how the resident completes personal hygiene was left blank, and the care plan did not indicate any refusal of care by the resident. Observations by the surveyor on multiple occasions revealed that the resident had chin hair approximately 1 inch long. During an interview, the resident confirmed their dislike for the chin hair and their wish for it to be removed. A Certified Nurse Aide (CNA) acknowledged that it was the responsibility of CNAs to remove chin hair but admitted to not having time to do so for the resident. The facility's policy on promoting and maintaining resident dignity emphasizes grooming according to resident preference, which was not adhered to in this case.
Failure to Notify Ombudsman and Issue Transfer Notices
Penalty
Summary
The facility failed to provide a notice of transfer and failed to send a copy of the notice to the Ombudsman for one resident, and failed to send a copy of the transfer notice to the Ombudsman for another resident. Resident #30, who was admitted with diagnoses including dementia, was transferred to the hospital due to critically low hematocrit and hemoglobin levels. The resident had been non-compliant with transfusion and lab draws, and expressed feeling weak, prompting the transfer. However, the facility did not issue a transfer notice to the resident or send a copy to the Ombudsman. Resident #22, admitted with diagnoses including heart failure and pulmonary hypertension, was transferred to the hospital following a fall and was later admitted for hypokalemia and congestive heart failure. The facility failed to document that the Ombudsman was notified of this transfer. Interviews with the Regional Nurse and the Director of Nurses confirmed the lack of transfer notices and notifications to the Ombudsman for both residents.
Failure to Provide Bed Hold Policy Before Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to two residents or their representatives before they were transferred to the hospital, which is a requirement according to the facility's policy. Resident #30, who was admitted with diagnoses including dementia and had impaired cognition, was transferred to the hospital due to critically low hematocrit and hemoglobin levels. Despite the emergency nature of the transfer, the facility did not issue a bed hold policy to the resident or their representative prior to the transfer. This was confirmed during an interview with the Regional Nurse and the Director of Nurses, who acknowledged the oversight. Similarly, Resident #22, who was cognitively intact and admitted with conditions such as heart failure and pulmonary hypertension, was transferred to the hospital following a fall and subsequent diagnosis of hypokalemia and congestive heart failure. The surveyor's review of the resident's medical records revealed no documentation of a bed hold policy being provided. The Regional Nurse was unable to locate any such documentation, confirming that the policy was not issued as required.
Failure to Complete Timely PASRR for Resident with SMI
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) in a timely manner for a resident with serious mental illness (SMI) after their stay exceeded the 30-day exemption period. The resident was admitted with diagnoses including bipolar disorder and depression, and initially had a positive SMI screen. However, a Level II PASRR Evaluation was not indicated at the time due to an Exempted Hospital Discharge, which allows for a maximum stay of 30 days without further screening. The facility was required to submit a Level I Screening to the Department of Mental Health by the 25th day if the stay was expected to exceed 30 days, but this was not done. Interviews revealed that the Admissions Liaison was responsible for PASRR Level I screenings only upon admission and was unaware of who was responsible for subsequent screenings after the previous staff member resigned. The Social Worker, who was a consultant, stated that no one in the facility had access to the PASRR portal to complete the necessary screenings and had informed the Administrator multiple times without resolution. The Administrator was unaware that the PASRRs were not being completed as required.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, which is a requirement to ensure effective and person-centered care. Resident #25, who was admitted with end-stage kidney disease, pneumonia, and a fracture, did not have a baseline care plan that included necessary instructions for dialysis treatment. The medical record lacked a doctor's order for hemodialysis, and there was no care plan addressing the monitoring of the Central Venous Catheter (CVC) for infection and drainage. Interviews with nursing staff confirmed the absence of a care plan and the expectation that such a plan should have been in place. Similarly, Resident #47, admitted with PTSD, hemiplegia, and diabetes, and Resident #49, admitted with a hip fracture and malnutrition, also did not have baseline care plans developed within the required timeframe. The Director of Nursing and nursing staff were unable to locate any baseline care plans for these residents in their medical records. The facility's policy on comprehensive care plans did not specify the need for a baseline care plan upon admission, contributing to the oversight.
Deficiencies in Comprehensive Care Plan Review and Revision
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised by the interdisciplinary team following the completion of comprehensive assessments. For one resident, the facility did not update the care plan to reflect a change in advanced directives from full code to do not resuscitate (DNR), despite a physician's order indicating the change. The care plan was overdue for review, and no care plan meeting was held to address this change. Interviews with staff revealed that the responsibility for updating care plans was unclear due to staffing issues, with the MDS nurse and social worker positions vacant or inadequately filled. For another resident, the facility did not review or revise the care plan to include specific details about high-risk medication use, such as the names of medications, associated diagnoses, or symptoms for use. The care plan was overdue for review, and the goals related to medication use were not specific or updated. The Director of Nursing acknowledged the lack of specific psychotropic medication use care plans and the overdue status of the care plan review. The facility's policies required that comprehensive care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. However, due to staffing challenges and lack of coordination, these requirements were not met, resulting in deficiencies in the care planning process for the residents involved.
Failure to Implement Physician's Orders for Air Mattress Settings
Penalty
Summary
The facility failed to provide services that met professional standards of quality for a resident with severe cognitive impairment, as evidenced by a BIMS score of 2 out of 15. The deficiency involved the improper setting of an air mattress, which was not adjusted according to the physician's orders. The physician had ordered a low air loss mattress to be set at 130, with checks every shift to maintain this setting for monitoring and prevention purposes. However, observations by the surveyor revealed that the air mattress was consistently set to 150, which was not in accordance with the physician's orders. Interviews with facility staff, including a CNA and a nurse, indicated a lack of adherence to the physician's orders and manufacturer guidelines for the air mattress settings. The CNA stated that they do not adjust air mattress settings, while the nurse acknowledged the need to verify and implement the physician's order. The Regional Nurse also confirmed that nursing staff should follow the physician's orders and manufacturer's guidelines for air mattress settings. The facility's policy on the use of support surfaces emphasized the importance of using these devices in accordance with physician orders and manufacturer recommendations, which was not followed in this case.
Failure to Implement Splint Use for Resident with Limited Range of Motion
Penalty
Summary
The facility failed to provide necessary services and treatment for a resident who had a reduction in range of motion in the left hand. The facility's policy required that any resident with limited range of motion receive treatment to increase and maintain their range of motion. However, the facility did not implement a plan of care or a splint-wearing schedule for the resident, despite recommendations from the occupational therapist. The resident, who was admitted with diagnoses including dysphagia and hemiplegia following a cerebral infarction, was observed multiple times without the prescribed left-hand splint and palm protector. Certified nurse assistants and nurses were unaware of the requirement for the resident to wear the splint, indicating a lack of communication and documentation regarding the resident's care plan and physician's orders. The occupational therapist had completed training with the nursing staff and recommended the use of a left-hand splint with a palm protector for over 8 hours during the day. Despite this, the nursing staff did not obtain or implement the necessary physician's orders for the splint use, leading to the deficiency in care for the resident.
Failure to Document Catheter Size in Physician's Orders
Penalty
Summary
The facility failed to document the size of an indwelling urinary catheter in the physician's orders for a resident, leading to a deficiency in care. The resident, who was admitted with a diagnosis of urine retention, had an indwelling catheter in place. Despite the facility's policy to ensure appropriate catheter care, the physician's orders and the care plan did not specify the size of the Foley catheter and balloon. This omission was noted during a review of the resident's records and confirmed through interviews with nursing staff. Observations revealed that the resident experienced discomfort and a foul-smelling discharge, which prompted catheter irrigation and cleaning by the nursing staff. However, the lack of documentation regarding the catheter size was highlighted during an interview with a nurse, who acknowledged the importance of this information in preventing resident discomfort. The catheter size was eventually identified as 16 French with a 10-milliliter balloon, which the resident found comfortable. The regional nurse confirmed that catheter sizes should be documented in the physician's orders.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for Resident #19, who was admitted with diagnoses including dementia, dysphagia, and osteoarthritis. The resident, who had severe cognitive impairment and was dependent on staff for eating, experienced significant weight loss over several months. Despite physician orders and care plans indicating the need for fortified foods and nutritional supplements, these were not consistently provided. Observations on two separate days revealed that the resident's breakfast trays lacked the prescribed fortified items such as chocolate shakes, fortified juices, fortified milk, super cereal, and yogurt. Interviews with staff, including a CNA, nurse, dietary staff, and the dietitian, confirmed the absence of these fortified items on the resident's meal trays. The dietary staff admitted to not preparing or providing the necessary fortified foods, and the dietitian was unaware that the resident was not receiving the prescribed fortified shakes. The facility's failure to provide these nutritional interventions contributed to the resident's continued weight loss, as documented in the resident's electronic health record and dietary notes.
Failure to Adhere to Enteral Feeding Guidelines
Penalty
Summary
The facility failed to adhere to professional standards for the administration of enteral feeding for a resident with dysphagia and hemiplegia following a cerebral infarction. The resident was admitted with a tube feeding requirement, and the facility's policy mandates that feeding tubes be used in accordance with current clinical standards and manufacturer's guidelines. However, the facility did not comply with these guidelines, as evidenced by the use of an expired enteral nutrition product. Specifically, a bottle of Jevity 1.2 was observed in the resident's room, which had been dated 9/6/24 and was still in use on 9/10/24, exceeding the manufacturer's recommended hang time of 24 to 48 hours. Interviews with facility staff revealed that the nursing staff did not change the Jevity bottle daily as required by the manufacturer's guidelines. Nurse #1, who worked the overnight shift, admitted to leaving the Jevity bottle up for use the next day, despite it being dated 9/6/24. The Regional Nurse confirmed that the nursing staff should have changed the bottle daily and followed the manufacturer's guidelines. This oversight in following the proper protocol for enteral feeding administration led to the deficiency identified by the surveyors.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents. For one resident, the facility did not ensure that a BiPAP machine, essential for managing sleep apnea and asthma, was repaired after it was identified as broken. Despite the resident's cognitive awareness and the presence of a physician's order for BiPAP use, the machine remained unusable for weeks. Staff, including a nurse and the Director of Nursing, were aware of the issue but did not document the malfunction or update the resident's care plan. The resident reported not sleeping well without the BiPAP, and there was no record of any repair request or plan to address the broken equipment. For another resident, the facility failed to administer oxygen therapy in accordance with professional standards and physician's orders. The resident, who required oxygen due to heart failure and other conditions, was observed receiving oxygen at a rate higher than prescribed during multiple observations. The physician's order specified a lower oxygen flow rate, but nursing staff did not adjust the settings accordingly. Interviews with staff revealed a lack of awareness regarding the correct oxygen settings, and the resident was not known to adjust the settings independently. This inconsistency in oxygen administration was not aligned with the resident's care plan and physician's orders.
Incomplete Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive plan of care for trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The facility's policy on trauma-informed care, dated March 2024, requires a multi-pronged approach to identify a resident's history of trauma and cultural preferences, including identifying triggers that may re-traumatize residents. However, the care plan for the resident admitted in August 2024 was incomplete, lacking specific triggers and interventions to mitigate the effects of PTSD episodes. Interviews with the Director of Nursing (DON) and the MDS Nurse confirmed the deficiency. The DON acknowledged that the PTSD care plan was not complete or resident-centered, and it should have included specific triggers and interventions. The MDS Nurse stated that care plans are supposed to be resident-specific with tailored interventions. The failure to include these critical elements in the care plan represents a deficiency in providing trauma-informed care to the resident.
Failure to Indicate Duration of PRN Antipsychotic Medication
Penalty
Summary
The facility failed to indicate the duration of a PRN antipsychotic medication for a resident, which is a requirement according to their policy on the use of psychotropic medications. The policy mandates that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration, typically 14 days. If the medication needs to be extended beyond this period, the attending physician must document the rationale and indicate the duration in the resident's medical record. In this case, the facility did not comply with this requirement for a resident who was prescribed Olanzapine as needed for agitation. The resident, who was admitted with diagnoses including borderline personality disorder, suicidal ideations, major depression disorder, and opioid abuse, had a PRN order for Olanzapine without a specified duration. The Psychiatric Nurse Practitioner recommended discontinuing the PRN Zyprexa, stating that antipsychotics should not be PRN unless scheduled. Despite this recommendation being communicated to the Director of Nurses, the facility did not address the issue within the expected timeframe, leading to a deficiency in the management of the resident's medication orders.
Failure to Follow Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to ensure that the physician-ordered therapeutic diet was followed for a resident with dysphagia and hemiplegia following a cerebral infarction. The resident was admitted with a tube feeding and was on a mechanically altered diet. Despite having a physician's order for a regular diet with dysphagia advanced texture and thin liquids, the resident was observed receiving a meal that did not comply with these specifications. The meal provided included breaded fish, whole coleslaw, whole French fries, and whole pineapple tidbits, which did not align with the prescribed diet of soft plain baked minced fish, soft minced carrots, mashed potatoes, and pureed fruit. Interviews with dietary staff revealed that the kitchen had recently changed food vendors and had not received updated therapeutic diet breakdowns. As a result, dietary staff were preparing meals based on memory of previous diets. The Food Service Director confirmed the lack of therapeutic diet breakdowns and stated that dietary staff should follow the diet as ordered. The Chief Nursing Officer and Regional Nurse both emphasized the importance of adhering to physician-ordered therapeutic diets, highlighting a breakdown in communication and procedure within the dietary department.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide adaptive equipment for a resident, specifically a lip plate, which was necessary for the resident's meals. The resident, admitted in November 2020, had diagnoses including dementia, dysphagia, and osteoarthritis, and was on a mechanically altered diet. The most recent Minimum Data Set (MDS) assessment indicated severe cognitive impairment and significant weight loss. Despite a physician's order dated April 2023 specifying the need for a lip plate on all meal trays, observations on two separate days in September 2024 revealed that the resident was served breakfast without the required lip plate. Interviews with various staff members, including a Certified Nurse Assistant, a nurse, the Food Service Director, and the Regional Nurse, confirmed that the kitchen was responsible for providing the lip plate. However, the failure to consistently provide this adaptive equipment was evident, as the resident did not receive the lip plate during the observed meals. This oversight highlights a lapse in the facility's adherence to its policy on adaptive feeding equipment, which mandates that the dietary department be notified of residents needing such equipment and that it be provided and maintained appropriately.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the facility's Administrator. The Health Care Facility Reporting System (HCFRS) indicated that a change in the facility administrator occurred on June 21, 2024, with Administrator #2 being the current Administrator. However, during an interview on September 10, 2024, Administrator #1 stated that he started on September 9, 2024. Further review of HCFRS showed no indication that the State Agency was notified when Administrator #1 assumed the role. Additionally, during an interview on September 12, 2024, Administrator #2 confirmed her last day was September 6, 2024. The Chief Nursing Officer acknowledged that the change in Administrator should have been reported to the State Agency but was not.
Failure to Provide Accurate Cost Estimates on ABN Notices
Penalty
Summary
The facility failed to provide an accurate estimated cost of services to residents or their representatives, which is necessary to inform them of their potential financial liabilities for services not covered by Medicare. This deficiency was identified through a review of records and interviews, affecting two residents who had transitioned off their Medicare Part-A benefits but remained at the facility. The Advanced Beneficiary Notices (ABNs) given to these residents did not include a detailed cost breakdown for services, which is required to help residents make informed decisions about continuing services that may not be covered by Medicare. During interviews, both the Business Office Manager and the Administrator acknowledged that the ABN notices lacked the necessary cost breakdown.
Failure to Transmit MDS Discharge Assessment Timely
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) discharge assessment was encoded and transmitted in a timely manner for one resident out of a total of 17 sampled residents. According to the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, a discharge MDS assessment must be completed within 14 days after the discharge date. The resident in question was admitted to the facility in April 2024 with diagnoses including pancreatitis and skin cancer. The MDS assessment dated April 18, 2024, indicated the resident's recent admission. However, the resident was discharged home on May 22, 2024, and the medical record did not show that an MDS discharge assessment was encoded or transmitted as required. Interviews with the Director of Nursing and the MDS Nurse confirmed that the discharge assessment was not completed, although it should have been according to RAI guidelines.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in their assessments. For one resident, who was admitted with a history of stroke and congestive heart failure, the MDS inaccurately indicated the use of anticoagulant and antiplatelet medications. A review of the Medication Administration Record (MAR) for the relevant period showed no administration of these medications, which was confirmed by both the Director of Nursing and the MDS Nurse during interviews. The MDS Nurse acknowledged the error in coding, as the resident did not receive the medications during the specified lookback period. Another resident, admitted with diagnoses including hip fracture and malnutrition, had their discharge location incorrectly coded in the MDS. The MDS indicated a discharge to an acute care hospital, while progress notes from nursing and social services documented a discharge to another long-term care facility. The MDS Nurse confirmed that the MDS was inaccurately coded, as the resident was indeed discharged to another nursing home. These inaccuracies in MDS coding reflect a failure in ensuring accurate resident assessments.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post nurse staffing information daily in a prominent place accessible to residents and visitors. The facility's policy, dated 3/4/24, mandates that the Nurse Staffing Sheet should be posted daily, containing details such as the facility name, current date, resident census, and the total number of hours worked by registered nurses, licensed practical nurses, and certified nurse aides. However, during observations on 9/10/24 and 9/12/24, the surveyor was unable to locate the nurse staffing information in the reception area, indicating non-compliance with the policy. Interviews revealed that the Scheduler, responsible for posting the information, admitted to forgetting to post it on 9/12/24 and confirmed that it was not posted on 9/10/24 due to her absence. Furthermore, the Scheduler stated that the information is not posted on weekends as no one else is assigned this responsibility. The Director of Nursing confirmed that the information should be posted daily, including weekends, highlighting a lapse in the facility's adherence to its staffing information posting policy.
Failure to Follow Established Meal Menus
Penalty
Summary
The facility failed to ensure that the Dietary/Kitchen Department staff consistently prepared and followed the established weekly menu for resident meals. The facility's policy required that menus be developed to meet resident choices and nutritional needs, be posted one week in advance, and be followed as posted. However, during a kitchen tour, it was observed that the breakfast and lunch meals served did not match the planned menu. For breakfast, hashbrowns and gravy were not available, and sausage, which was not on the menu, was served instead. For lunch, a cold tuna sandwich was served instead of the planned tuna melt, and the alternate meal was a grilled cheese sandwich instead of honey Dijon chicken. Interviews with staff revealed that there were issues with Cook #1 not following the planned meal menus, which led to deviations from the posted menu. It was noted that there were missing ingredients for the lunch meal, and Cook #1 had previously used ingredients intended for future meals, causing further menu deviations. A resident reported being served random food not on the planned menu and often having no alternate meal choice other than peanut butter and jelly sandwiches. The facility administrator acknowledged that meal menus should be followed as planned but were not.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food and beverages provided to residents were served at safe and appetizing temperatures. The facility's policies required hot foods to be maintained at or above 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. However, during a test tray observation, it was found that the food items were not served at these temperatures. For instance, a cold tuna sandwich was served at 69.1 degrees Fahrenheit, and mixed vegetables were at 106.9 degrees Fahrenheit, both outside the acceptable temperature range. Additionally, the food was described as bland, with the sandwich being soggy and the tater tots undercooked and cold. The facility's records indicated a lack of consistent measurement and recording of food temperatures. The Service Line Checklist Logs showed numerous instances where no food temperatures were recorded for various meals throughout August and early September. Staff interviews revealed that food temperatures should be measured and documented with every meal, but this was not consistently done. The facility's kitchen staff admitted to not measuring food temperatures due to being too busy, and there was a lack of sufficient food prepared for test trays. Residents expressed dissatisfaction with the quality and temperature of the food. During interviews, residents complained about the food being unappetizing, with one resident stating that breakfast was atrocious and lacking in protein. Another resident mentioned that the lunch sandwich had very little filling and was difficult to identify as tuna or chicken salad. Staff also acknowledged the residents' complaints, with one nurse offering alternative food options like peanut butter and jelly sandwiches. The facility had recently hired a new Food Service Director, but the interim director was filling in until the new director started. The administrator was unaware of the use of paper plates and had not reviewed the Food Committee Meeting Minutes until prompted by the surveyor.
Inconsistent Documentation of Weekly Skin Assessments
Penalty
Summary
The Facility failed to maintain complete and accurate medical records for two residents, as required by their policies. For one resident, who was admitted in April 2024 with diagnoses including epilepsy and hypertension, the Facility's records showed that weekly skin checks were not documented for several weeks. Specifically, there was no documentation for the weeks of April 29, May 6, May 13, and May 20, 2024, and no further documentation after May 27, 2024, despite the care plan indicating that weekly skin checks should be conducted. For another resident, admitted in September 2021 with diagnoses including nontraumatic subarachnoid hemorrhage, dysphagia, and anxiety, the Treatment Administration Record indicated that weekly skin checks were scheduled and marked as completed in August 2024. However, the Medical Record lacked completed Weekly Skin Assessment Forms for two of those weeks, specifically August 14 and August 21, 2024. The Director of Nurses confirmed that weekly skin checks should be documented in the electronic medical record, but this was not done consistently.
Delayed Notification of Resident's Death to HCA and Hospice
Penalty
Summary
The facility failed to notify the Health Care Agent (HCA) and the Hospice Agency in a timely manner following the death of a resident who was under hospice care. The resident, who had multiple diagnoses including respiratory failure and congestive heart failure, was admitted to hospice services and had an activated Health Care Proxy. The resident passed away shortly after midnight, but the HCA and Hospice Agency were not informed until approximately eight hours later when a family member arrived at the facility expecting to visit the resident. The delay in notification was attributed to the actions of the former Director of Nurses (DON), who was responsible for pronouncing the death but did not do so promptly. A Licensed Practical Nurse (LPN) on duty at the time was unable to pronounce the death and was waiting for the former DON to complete the pronouncement before notifying the HCA and Hospice Agency. The LPN later realized that she could have contacted the Hospice Agency directly, which could have sent a nurse to pronounce the death. The current DON acknowledged the delay and stated that it was expected for nursing staff to notify the relevant parties immediately after a resident's death.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 573 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newburyport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Port Rehabilitation And Healthcare Center | 1.1 mi | ★★★★★ | 20 | 0 |
| Adviniacare Newburyport | 1.5 mi | ★★★★★ | 9 | 0 |
| Maplewood Center | 4.3 mi | ★★★★★ | 0 | 0 |
| Mill Town Health And Rehabilitation | 5.1 mi | ★★★★★ | 7 | 0 |
| Lakeview House Skld Nrsg And Residential Care Fac | 9.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.