Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tremont Rehabilitation & Skilled Care Center during CMS and state inspections, most recent first.
Nursing staff failed to follow physician orders for PRN oxycodone for two residents by giving the narcotic when pain scores were below the ordered 6-10 range, and staff acknowledged the orders were not followed as written. In addition, a resident with hemiplegia/hemiparesis and dementia continued to wear a left palm guard after the order had been discontinued, because the Resident Care Card was not updated and staff kept applying it based on the outdated reference.
The facility failed to maintain an accurate infection surveillance program and failed to store a resident’s nasal cannula tubing in a sanitary manner. The DON and IP confirmed that the line listings used for infection tracking were incomplete and inaccurate, with missing or incorrect onset dates, signs and symptoms, culture data, and germ results for residents listed with UTI and PNU. In addition, a resident with COPD and other respiratory diagnoses had oxygen tubing observed wrapped on a walker and lying on bed linens instead of being kept in a plastic bag when not in use.
The facility failed to develop and implement a smoking policy for independent smokers, even though 8 of 16 smokers were identified as independent. The policy addressed supervised smoking, designated smoking times, and secure storage of smoking materials, but the DON and Administrator said it did not include a process for independent smokers. Surveyors observed residents smoking outside the designated area, including in the front walkway and visitor parking lot, and one resident had a lighter and smoking materials in the room.
Unlabeled and improperly stored medications were found in a Unit B med cart. A clear plastic cup with Preservision tablets was being used without the pharmacy container, another uncovered unlabeled cup contained 13 unidentified pills, and topical items such as muscle rub, wound ointment, and mineral oil were stored with oral meds and inhalers. The LPN said unlabeled meds should never be left in the cart and that external-use products should be kept in the treatment cart; the DON stated meds should remain in their pharmacy-labeled packaging and external-use meds should be stored separately from oral meds.
Missing Transfer and Bed-Hold Documentation for Hospitalized Residents: The facility failed to provide written transfer/discharge notices and bed-hold documentation for two residents who were sent to the hospital, and the forms were not kept in the medical record. Both residents had severe cognitive impairment, and staff interviews showed that nursing and social services were not consistently completing or filing the required paperwork, with forms often handled after the resident had already left the facility.
The facility failed to provide an adequate activity program for residents on the B Unit, particularly for two residents with severe cognitive impairment. Despite their preferences for activities like music, pet therapy, and outdoor engagement, the activity logs showed minimal participation and lack of offered activities. Observations revealed residents often left without engagement or materials for self-directed activities, with scheduled activities frequently not conducted.
The facility failed to maintain infection control standards by not storing a resident's nebulizer equipment properly and not ensuring staff wore appropriate PPE for residents on Enhanced Barrier Precautions (EBP). Staff were observed providing care without gowns for residents with PICC lines and ESBL, despite posted precautionary signs. The Director of Nurses confirmed the expectation for gown usage during high-contact care activities.
A resident with chronic venous insufficiency and thrombosis was prescribed chewable aspirin for faster absorption. However, a nurse failed to separate the aspirin from other medications and did not prompt the resident to chew it, leading to the resident swallowing it whole. The nurse and DON acknowledged the error, noting that medications should be administered per physician's orders.
A resident with visual and cognitive impairments was found with unsecured medications left at their bedside, despite not being evaluated or authorized to self-administer. Nursing staff confirmed the resident's inability to self-administer due to their condition, and the facility's policy requiring observation during medication administration was not followed.
A facility failed to ensure a resident receiving Seroquel underwent a gradual dose reduction (GDR) unless clinically contraindicated. Despite the facility's policy, there was no documented attempt to reduce the dosage, and the resident continued to receive the medication without a GDR. Interviews revealed a lack of documentation and clinical rationale for not initiating a GDR, which was only addressed following surveyor inquiry.
A facility failed to secure medications properly, allowing a psychiatric NP unsupervised access to a medication room containing various drugs. A nurse unlocked the room for the NP, who entered alone to make a call. Interviews revealed staff believed this was acceptable, but the Administrator confirmed only nurses should access the room.
A resident with multiple food allergies and intolerances was repeatedly served meals containing allergens like gluten and onions, despite clear dietary restrictions. The resident expressed concerns about the facility's carelessness, leading to reliance on limited safe food options. Staff interviews revealed inadequate adherence to dietary restrictions and meal preparation practices.
The facility failed to ensure physician's orders for hospital transfers for four residents and did not follow orders for blood pressure checks before administering antihypertensive medication to a resident. Additionally, there was a lack of proper orders and documentation for PICC line flushing for a resident receiving IV antibiotics.
The facility failed to lock medication carts when unattended and improperly stored medicated cream at a resident's bedside. A medication cart was repeatedly left unlocked in the hallway, and a resident with a g-tube had medicated cream on their nightstand without proper authorization. Staff interviews confirmed these practices were against facility policy.
The facility failed to maintain clean and sanitary conditions in the main kitchen and unit kitchenettes, with dust and debris observed in various areas. Additionally, food items were not properly labeled or dated, leading to potential food safety issues. The FSD acknowledged the lack of coordination in cleaning responsibilities and the need for proper labeling and dating of food items.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in COVID-19 testing and PPE use. Staff did not adhere to manufacturer's guidelines for COVID-19 testing, reading results prematurely. PPE was not properly donned and doffed, with staff failing to sanitize eye protection or change N95 masks after exiting COVID-19 positive rooms. Additionally, a resident was observed flushing their G-tube without performing hand hygiene, highlighting a lapse in infection control practices.
The facility failed to notify the physician of significant treatment changes for two residents. One resident's psychiatric medication adjustments were not communicated or implemented, while another resident's STAT lab orders were delayed without informing the physician. Interviews confirmed lapses in communication and documentation.
A resident with Alzheimer's and a history of falls was transferred to the hospital without necessary communication from the LTC facility. Despite protocols requiring an SBAR tool and physician's order, these were not completed due to the emergency nature of the transfer. Only demographic information and an advanced directive were sent with the resident.
A facility failed to complete a quarterly smoking evaluation for a resident with dementia and hypertension, as required by their smoking policy. The resident, who was cognitively intact, last had a smoking assessment in April, but it was not updated by July as required. Interviews with the UM and DON confirmed the oversight.
Two residents with mental health diagnoses did not receive necessary behavioral health care due to the facility's failure to implement recommended medication changes and update care plans. One resident experienced suicidal ideation and sleep disturbances, while the other exhibited mood fluctuations and paranoid behavior. The facility did not communicate these issues to the residents' representatives or attending physicians.
The facility failed to conduct a comprehensive facility-wide assessment, omitting critical information on residents' special treatments and conditions, such as respiratory support and therapy needs. The assessment also did not include the ADON in the staffing plan and inaccurately identified the managing health care system. The Administrator acknowledged these deficiencies, admitting the assessment was inaccurate.
Pain Medications Given Outside Ordered Parameters; Discontinued Palm Guard Still Applied
Penalty
Summary
Professional standards of nursing practice were not maintained when narcotic pain medications were administered outside of the prescribed pain-score parameters for two residents. One resident was admitted with chronic pain and had an order for oxycodone 5 mg every 6 hours as needed for severe pain rated 6 to 10 on the pain scale. Review of the MAR showed the medication was given multiple times when the resident’s pain was documented below the ordered threshold, including ratings of 5, 4, 3, and even 0 out of 10. A nurse who administered the medication acknowledged that the resident had received oxycodone multiple times for pain levels below the ordered parameter, and the Unit Manager confirmed the order had not been followed as written. A second resident, admitted with hypertension, peripheral vascular angioplasty, and recent right knee arthroplasty, had an order for oxycodone 10 mg every 4 hours as needed for severe pain rated 6 to 10 on the pain scale. Review of the MAR showed the resident received oxycodone numerous times when pain was documented below the ordered range, including ratings of 5, 4, 3, and 0 out of 10. A nurse stated the resident had received the medication outside of the ordered parameters, and both the Unit Manager and DON reviewed the MARs and stated the nurses did not follow the physician’s prescribed parameters. Professional standards were also not maintained for a resident with left-sided weakness and dementia when a left palm guard continued to be applied after it had been discontinued. The resident had a history of intracerebral hemorrhage with hemiplegia and hemiparesis affecting the left dominant side, and therapy documentation indicated the hand splint had been discontinued from the plan of care. The physician’s order for the left palm guard was discontinued because it was no longer needed, and the care plan history showed the intervention was resolved. However, the resident was observed wearing the left palm guard after discontinuation, and the Resident Care Card still listed the palm guard as being used at all times. Staff interviews confirmed the card had not been updated when the order was discontinued, and the DON stated the palm guard should not have been applied after it was discontinued.
Incomplete infection surveillance and improper storage of oxygen tubing
Penalty
Summary
The facility failed to maintain an infection prevention and control program with a complete and accurate surveillance system to identify trends or potential infections. The facility’s policy stated that the Infection Preventionist was responsible for ongoing collection and analysis of data, monitoring and documenting infections, tracking and analyzing outbreaks, and performing surveillance and investigation of infections. The facility also used McGeer criteria to determine whether illnesses met the definition of infection for surveillance purposes, and the Infection Preventionist confirmed that the line listing sheets were intended to track signs and symptoms, culture information, and germ results so residents could be monitored for possible links or outbreaks. Review of the November 2025 through January 2026 surveillance line listings showed multiple inaccuracies and omissions. For a resident listed with UTI, the line listing did not include culture results, and the signs and symptoms recorded did not meet McGeer criteria for a UTI. Three additional UTIs were also missing culture date or germ results. For a resident listed with pneumonia, the line listing did not reflect the correct onset date and did not include the signs and symptoms that would indicate pneumonia; four additional residents listed for pneumonia lacked chest x-ray results, and one UTI lacked culture results. The monthly infection analysis for December 2025 also failed to indicate any respiratory infections, despite residents being listed on surveillance for pneumonia. Additional review in January 2026 showed more incomplete and inaccurate surveillance entries. One resident listed with pneumonia had a chest x-ray positive for pneumonia, but the line listing did not include all documented signs and symptoms, including wheezes. Another resident listed with UTI had dysuria recorded, but the onset date was incorrect and the culture date and site were blank. A resident listed with ESBL urine had confusion and lethargy recorded, but the onset date was incorrect and the line listing did not include the germ identified in the results. The Infection Preventionist and DON both acknowledged that the surveillance sheets were incomplete and inaccurate and that required signs and symptoms, onset dates, and germ results were not consistently documented. The facility also failed to ensure nasal cannula oxygen tubing for one resident was stored in a sanitary manner. The resident had diagnoses including COPD, acute respiratory distress syndrome, and obstructive sleep apnea, and was cognitively intact. The resident stated that the oxygen tubing was used with a walker and in the room, but there was no plastic bag available to store it when not in use. Observations showed the tubing wrapped around and hanging from the walker handlebars and later lying across the bed linens, with no plastic storage bag present. The DON stated the tubing should have been stored in plastic storage bags when not in use, but this was not occurring for the resident.
Smoking Policy Did Not Address Independent Smokers
Penalty
Summary
The facility failed to develop and implement a smoking policy that included a process for independent smokers, designated smoking areas, proper receptacles for safe cigarette disposal, and storage of lighting and smoking materials for 8 of 16 current smokers. The facility policy stated that residents who smoke would be evaluated for safe smoking, that all cigarettes and smoking materials would be kept in a secure location, and that smoking would occur at scheduled times in a designated smoking area under staff supervision. However, the DON and Administrator both stated the policy was designed more for supervised smokers and did not include a process for independent smokers. During interviews, staff reported that independent smokers were allowed to keep their own lighters and smoking materials and were expected to sign out and leave the property to smoke. The Smoking Attendant stated she was only responsible for supervised smokers and their smoking materials and lighter. The Unit Manager identified 8 of 16 smokers as independent smokers, and the Administrator acknowledged that the policy did not include information on independent smokers and that the facility would need to revise it because the current policy said residents were not allowed to smoke anywhere on the grounds. Survey observations showed independent smokers smoking outside the facility in areas other than the designated smoking area. One resident was observed outside the front door using a lighter kept in a jacket pocket, another was observed smoking in the visitor parking lot, and another had a cigarette lighter on an overbed table in the room and stated permission had been given to keep it there. A resident also stated that independent smokers typically sat in the parking lot because of snow and was observed ashing cigarettes and throwing butts on the ground while standing in the parking lot with a walker.
Unlabeled and Improperly Stored Medications in Medication Cart
Penalty
Summary
The facility failed to ensure that medications were labeled and stored in accordance with accepted professional principles in one of two medication carts observed. During an observation with interview on the Unit B medication cart, a clear plastic drinking cup laying on its side and uncovered contained numerous brown, oval-shaped tablets with handwritten labeling on the outside that said Preservision; Nurse #1 stated these were eye vitamins used for house stock and said they should not be in use without the pharmacy container with the medication information. In the same cart, a clear plastic uncovered, unlabeled medication cup contained 13 pills of different colors, shapes, and sizes; Nurse #1 said she did not prepare the medication, did not know what the pills were, and stated medications should never be left unlabeled and stored in the medication cart. The observation also found topical and external-use items stored with oral medications in the medication cart. In the second drawer, adjacent to handheld respiratory inhalers, there was one tube of muscle rub cream, one tube of wound dressing ointment, and a bottle of mineral oil with handwritten labeling on the cap reading mineral oil for scalps. Nurse #1 stated these items are to be applied to skin or wounds and should not be stored in the medication cart, and that skin and wound care medications should be stored in the treatment cart. The DON later stated that all medications should be stored in the packaging they were received in with the pharmacy label and that external-use medications must be stored in the treatment cart, away from oral medications.
Missing Transfer and Bed-Hold Documentation for Hospitalized Residents
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold documentation for two residents who were sent to the hospital, and the information was not maintained in the medical record. The facility policies reviewed stated that hospitalized residents’ beds would be reserved in accordance with facility policy and regulations, and that written notification to the resident or responsible party would be provided prior to transfer/discharge or as soon as practicable for an unplanned transfer. Resident #1 was admitted with diagnoses including vascular dementia, adult failure to thrive, and hypertension. The resident’s MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The medical record showed hospital transfers in June 2025 and November 2025, but there was no documentation that bed-hold or transfer notices were provided to the resident or representative before transfer, and no evidence in the record that these forms were sent with the resident. Resident #8 was admitted with diagnoses including Alzheimer’s disease, dementia, and delusional disorder. The resident’s MDS showed a BIMS score of 6 out of 15, also indicating severe cognitive impairment. The medical record showed hospital transfers in October 2025 and December 2025, but again there was no documentation that bed-hold or transfer notices were provided. Interviews with nursing, social work, and leadership staff indicated that transfer and bed-hold forms were not being completed as part of the resident record, were kept in a social services binder instead of the medical record, and were often completed after the resident had already been sent to the hospital.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents on the B Unit, specifically for two residents. Resident #6, who has severe cognitive impairment and a preference for activities such as reading, music, and going outside, was not offered these activities according to their comprehensive assessment. The activity participation logs showed limited engagement in activities, with many days having no recorded participation, and no evidence of being offered outdoor activities or religious groups. Similarly, Resident #48, also with severe cognitive impairment, expressed preferences for music, pet therapy, and outdoor activities, but the activity logs indicated minimal participation and no evidence of being offered these preferred activities. The activity care plans for both residents lacked interventions for their stated preferences, and the Activity Director could not explain the lack of participation in programming according to their comprehensive assessments. Observations of the B Unit's dayroom revealed that residents were often left without engagement or materials for self-directed activities. Staff presence was minimal, and scheduled activities were frequently not conducted. Interviews with staff and family members highlighted a lack of engagement and insufficient activity programming, with the Activity Director and Unit Manager unable to provide explanations or solutions for the deficiencies observed.
Infection Control Deficiencies in PPE Usage and Equipment Storage
Penalty
Summary
The facility failed to maintain sanitary conditions for a resident's nebulizer equipment. The nebulizer tubing and mask were observed lying on the bed without being stored in a plastic bag, exposing them to potential germs and environmental debris. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), confirmed that they were not provided with a storage bag for the nebulizer parts. Staff interviews revealed that the nebulizer equipment should have been stored in a plastic bag to prevent contamination, but this practice was not followed. The facility also failed to ensure that staff wore appropriate personal protective equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). For one resident with a peripherally inserted central catheter (PICC) line, nurses were observed administering intravenous antibiotics without wearing gowns, despite the requirement to do so for high-contact care activities. The nurses acknowledged their oversight, and the Director of Nurses confirmed that the expectation was for staff to wear both gloves and gowns during such procedures. Additionally, the facility did not enforce proper PPE usage for another resident on EBP and contact precautions due to a history of Extended-Spectrum Beta-Lactamase (ESBL) in the urine. Certified Nurse Aides (CNAs) were observed assisting the resident without wearing gowns, contrary to the posted precautionary signs. The CNAs admitted to not being aware of the need for gowns, and the Director of Nurses confirmed that gowns should have been worn during high-contact care activities.
Failure to Administer Chewable Aspirin as Prescribed
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration for one resident. Specifically, the deficiency involved the administration of chewable aspirin to a resident with chronic venous insufficiency and chronic embolism and thrombosis of deep veins. The physician's order required the aspirin to be chewed for faster absorption, but the nurse did not separate the chewable aspirin from other medications and did not prompt the resident to chew it. Instead, the nurse administered the aspirin along with other medications in a single cup, leading to the resident swallowing it whole. During the survey, the nurse acknowledged the error, stating that medications should be administered per physician's orders and that the physician should be notified if there are any issues. The Director of Nursing confirmed that the chewable aspirin should have been separated and chewed, and if the resident was unable to chew it, the physician should have been contacted for an alternative order. This oversight in medication administration was observed and documented by the surveyor, highlighting a failure to follow the prescribed medication protocol.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure a safe medication administration environment for a resident with visual disturbances, mild cognitive loss, and dysphagia. The resident, who was not evaluated or authorized to self-administer medications, was found with unsecured medications left at the bedside. The medications included two red large oval gel caps, three small white round pills, and a cup of light orange liquid, which the resident could not identify. The resident expressed that the medications were left for them to take at their convenience, as the nurses were busy. Interviews with nursing staff confirmed that the resident was not capable of self-administering medications due to visual impairment and intermittent confusion. The facility's policy required licensed nurses to observe residents taking their medications to ensure they were swallowed, a process that was not followed in this instance. The Director of Nurses acknowledged that the resident did not want to self-administer medications and that the medications should not have been left at the bedside.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication, specifically Seroquel, underwent a gradual dose reduction (GDR) unless clinically contraindicated. The resident, who was admitted in September 2022, had diagnoses including Alzheimer's disease, major depression, and anxiety, and was receiving Seroquel on a routine basis. Despite the facility's policy requiring antipsychotic medications to be prescribed at the lowest possible dosage and subject to GDR, there was no documented attempt to reduce the dosage of Seroquel for this resident. The Minimum Data Set assessment indicated that a GDR had not been attempted, and the physician's orders and medication administration records confirmed the continued administration of Seroquel without a GDR. Interviews with the psychiatric Nurse Practitioner and the Director of Nursing revealed that there was a lack of documentation regarding the evaluation of Seroquel for a GDR and no clinical rationale provided for not initiating a GDR. The physician acknowledged the oversight and directed her scribe to add an addendum to her progress note, indicating that a GDR was contraindicated. However, this documentation was only provided following the surveyor's inquiry, highlighting the facility's failure to adhere to its policy on psychotropic medication management.
Unauthorized Access to Medication Room
Penalty
Summary
The facility failed to ensure that all medications were securely stored in accordance with professional principles, as observed during a survey. Specifically, a consultant psychiatric Nurse Practitioner (NP) was allowed unsupervised access to a medication room, which contained various medications including emergency kits with anticoagulants, insulin, antibiotics, and antipsychotic medications. This occurred when Nurse #2 unlocked the medication room for NP #3, who then entered and closed the door to make a telephone call. During interviews, Nurse #2 and another nurse at the nursing station indicated that they believed it was acceptable for NP #3 to be in the medication room alone. However, the facility's Administrator later confirmed that only nurses should have access to the medication room and that NP #3 should not have been allowed to enter and remain there unaccompanied. This incident highlights a breach in the facility's medication storage policy, which mandates that medications be stored in a locked room accessible only to licensed nursing personnel.
Failure to Accommodate Resident's Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodated the allergies, intolerances, and preferences of a resident, leading to a deficiency. The resident, who was admitted with multiple food allergies and intolerances, including gluten and onions, was served meals containing these allergens. Despite the resident's medical records and meal tickets clearly indicating these dietary restrictions, the facility repeatedly served inappropriate meals, such as beef stew with gluten and onions, and sausage, which the resident could not consume. The resident expressed concerns about the facility's carelessness with food choices, stating that consuming these foods would cause severe gastrointestinal distress. The resident had communicated these issues to the dietitian and ombudsman but found limited resolution. The resident relied on limited safe food options like Cheerios, apple juice, and protein powder stored in their room due to fear of consuming unsafe meals provided by the facility. Interviews with staff, including the Food Service Director and nursing staff, revealed a lack of adherence to dietary restrictions and inadequate meal preparation practices. The Food Service Director admitted to using the same toaster for gluten-free and regular bread, potentially causing cross-contamination. The facility's failure to provide appropriate meals and snacks that met the resident's dietary needs and preferences was evident, as the resident frequently received meals that were not suitable for their condition.
Deficiencies in Physician Orders and Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders were in place for the transfer of four residents to the hospital. Residents with various diagnoses, including cirrhosis of the liver, Alzheimer's disease, dementia, and atrial fibrillation, were transferred to the hospital without documented physician's orders. Interviews with nursing staff and management confirmed that there was an expectation for such orders to be documented, but this was not consistently done. Additionally, the facility did not adhere to a physician's order for a resident with hypertension and heart failure. The order required that the resident's blood pressure and pulse be checked before administering Metoprolol Tartrate, an antihypertensive medication. However, the nurse failed to check the vital signs before administering the medication, as confirmed by the nurse and the unit manager during interviews. The facility also failed to follow professional standards of practice regarding the flushing of a PICC line for a resident receiving intravenous antibiotics. There was no physician's order for flushing the PICC line before and after medication administration, and the documentation was inconsistent. The nurse involved indicated that she followed protocol, but there was no order or proper documentation to verify that the flushes were performed as required.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medication and treatment carts were locked when not under the direct supervision of a licensed nurse. Observations by the surveyor revealed that a medication cart on Unit A was repeatedly left unlocked and unattended in the hallway, with keys left in the lock. This occurred on multiple occasions over several days, despite the facility's policy requiring medication carts to be locked when not in use. Interviews with Nurse #1 and the Director of Nursing confirmed that the carts should not be left unlocked and unattended, especially with keys in the lock. Additionally, the facility did not ensure the safe storage of medications and biologicals according to current standards of practice. A resident with a gastrostomy tube and moderate cognitive impairment was observed to have a clear plastic medication cup with medicated cream on their nightstand over several days. The cream was intended for use around the resident's g-tube site, as per physician's orders. Nurse #1 was unaware of the cream's presence on the nightstand, and the Director of Nursing stated that medications should not be left at a resident's bedside unless in a locked drawer with an order to self-administer.
Facility Fails to Maintain Sanitary Conditions and Proper Food Labeling
Penalty
Summary
The facility failed to maintain the main kitchen and unit kitchenettes in a clean and sanitary condition, as observed by the surveyor. In the main kitchen, there was a noticeable layer of dust on exposed ceiling piping, walls, and bulkheads, with some areas of the piping located above food preparation areas. The walk-in refrigerator had condensation issues, with drips of condensation on food items and packaging, and a buildup of soil and debris around the perimeter of the floor. The walk-in freezer also had debris on the floor and underneath the shelving. The Food Service Director (FSD) acknowledged these issues and noted that cleaning the walls and pipes in the main kitchen was not part of the cleaning checklists, and there was no coordination among departments for regular cleaning. In the unit kitchenettes, there was soil buildup on the floors, sticky residues on refrigerator shelving, and discolored grout that was slimy to the touch. The ice and water machines had residue or buildup on the interior of the ice chute. The FSD stated that maintenance was responsible for cleaning the interior of the ice/water machines, while dietary aides and housekeeping were responsible for cleaning the unit kitchenettes. However, the cleaning schedules provided did not include specific tasks for cleaning the areas observed to be dirty, and there was a lack of coordination between departments for cleaning responsibilities. The facility also failed to ensure that food items were properly labeled, dated, and stored in both the main kitchen and unit kitchenettes. In the main kitchen, there were several opened and unlabeled food items in the walk-in refrigerator and freezer, as well as undated items in the dry storage room. In the unit kitchenettes, there were opened cartons of thickened liquids and other food items that were undated, despite manufacturer labels indicating specific storage durations. The FSD and Assistant FSD acknowledged that all food and drink items should be labeled and dated, and any items without labels or dates should be discarded.
Infection Control Deficiencies in COVID-19 Testing and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. Firstly, the facility did not adhere to the manufacturer's guidelines for COVID-19 testing during an outbreak. Staff members were observed reading test results before the recommended 15-minute waiting period, which could lead to inaccurate results. The Infection Control Nurse and the Director of Nurses acknowledged that testing should be conducted according to the manufacturer's instructions, and staff should not report to work before the test results are confirmed. Secondly, the facility did not ensure that Personal Protective Equipment (PPE) was donned and doffed according to current professional standards. Staff members, including a housekeeper, a CNA, an activities assistant, and a nurse, were observed exiting rooms with COVID-19 positive residents without properly sanitizing their eye protection or changing their N95 masks. The Director of Nurses confirmed that staff should follow CDC guidance for PPE use, including sanitizing eye protection and obtaining a new N95 mask after exiting a COVID room. Lastly, the facility failed to ensure that Resident #48 performed hand hygiene before flushing their gastrostomy tube (G-tube). The resident, who had a diagnosis of malignant neoplasm of the pharynx and moderate cognitive impairment, was observed flushing their G-tube without performing hand hygiene. The Unit Manager and the Director of Nursing acknowledged that a competency assessment should have been completed before allowing the resident to flush their own G-tube.
Failure to Notify Physician of Treatment Changes
Penalty
Summary
The facility failed to notify the physician and the resident representative of significant changes in treatment for two residents. For one resident, who was admitted with multiple psychiatric and cognitive impairments, the Psychiatric Mental Health Nurse Practitioner recommended adjustments to psychotropic medications due to mood fluctuations and paranoid behavior. However, these recommendations were not communicated to the attending physician or implemented, as evidenced by the absence of documentation in the medical records and interviews with facility staff. The resident continued to exhibit adverse behaviors, and the resident representative was unaware of any medication changes. For another resident with chronic renal failure and bilateral nephrostomy tubes, a STAT order for blood tests was not fulfilled in a timely manner. The lab was unable to draw the required labs on the day they were ordered, and the facility staff failed to inform the physician of this delay. The labs were eventually drawn the following day, but the physician was not notified of the initial failure to obtain the STAT labs, which could have influenced the physician's decision regarding the resident's care. Interviews with the Director of Nursing confirmed that the facility's nursing staff did not follow proper procedures for notifying physicians of significant changes or issues in treatment. The lack of communication and documentation regarding the psychiatric recommendations and the delay in obtaining STAT labs contributed to the deficiencies identified by the surveyors.
Failure to Communicate Necessary Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that necessary information was communicated to the receiving health care institution during the transfer of a resident, leading to a deficiency. Resident #36, who was admitted in June 2023 with Alzheimer's Disease and a history of repeated falls, was transferred to the hospital after being found on the floor. The Minimum Data Set (MDS) assessment indicated that the resident was discharged to the hospital with return anticipated. However, there was no evidence of communication from the facility to the hospital regarding the transfer. Interviews with staff revealed that the facility's protocol for hospital transfers involves completing an SBAR tool in the electronic medical record, which was not done in this case due to the emergency nature of the transfer. The Assistant Director of Nursing confirmed that a physician's order and SBAR should be documented, but this was not completed for Resident #36. Nurse #6, who was on duty during the transfer, stated that only the resident's demographic information and advanced directive were sent to the hospital, with no additional documentation provided.
Failure to Complete Quarterly Smoking Evaluation
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards by not completing a required quarterly smoking evaluation and safety screen. According to the facility's smoking policy, residents who smoke must be evaluated for their ability to smoke safely upon admission, quarterly, and after any significant change in condition. This evaluation is necessary to determine if the resident can smoke without posing a danger to themselves or others, and any required assistive or safety devices should be noted in the resident's care plan. The resident in question was admitted in June 2021 with diagnoses of dementia and hypertension and was cognitively intact with a BIMS score of 14 out of 15. The last smoking evaluation for this resident was completed in April 2024, and the next one was due by July 2024. However, as of early August 2024, the evaluation had not been completed. Interviews with the Unit Manager and the Director of Nurses confirmed that the smoking assessments should be conducted quarterly, and the oversight was acknowledged upon review of the resident's medical record.
Failure to Implement Behavioral Health Care Plans for Residents
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents, leading to deficiencies in maintaining their highest psychosocial well-being. Resident #34, who was admitted with multiple mental health diagnoses including depression and anxiety, experienced a change in condition marked by suicidal ideation. Despite a recommendation from Nurse Practitioner (NP) #2 to initiate Remeron for insomnia and depression, the medication was not ordered, and the resident's care plan was not updated. The resident's representative was not informed of the change in condition or the medication recommendation, and the resident continued to experience sleep disturbances due to environmental noise. Similarly, Resident #9, who was admitted with severe cognitive impairment and multiple psychiatric diagnoses, did not receive timely adjustments to their medication regimen as recommended by NP #2. The NP suggested increasing Lamictal, discontinuing Seroquel, and starting Risperdal to address mood fluctuations and paranoid behavior. However, these recommendations were not implemented, and the resident continued to exhibit adverse behaviors, including crying and yelling, without any documented follow-up or communication with the attending physician. The facility's failure to act on the NP's recommendations and update the residents' care plans resulted in ongoing behavioral health issues for both residents. The lack of communication with resident representatives and attending physicians further exacerbated the situation, leaving the residents without the necessary interventions to address their mental health needs.
Inaccurate Facility Assessment and Resource Identification
Penalty
Summary
The facility failed to conduct and implement a comprehensive facility-wide assessment that accurately identified the resources necessary to provide both emergency and day-to-day care for the resident population. Specifically, the Facility Assessment Tool was found lacking in several critical areas. It did not accurately identify the number or range of residents with special treatments and conditions, such as those requiring respiratory support, oxygen therapy, or CPAP/BiPAP. Additionally, it failed to account for residents with G-tube feeding, falls, indwelling catheters, pain management needs, urinary tract infections, and other conditions requiring specific medical interventions. The tool also omitted information on residents receiving various therapies, such as physical, occupational, and speech therapy, and those experiencing excessive weight loss or pressure ulcers. Furthermore, it did not list medications like insulin, anticoagulation therapy, diuretics, opioids, hypnotics, anti-anxiety, and anti-psychotic drugs. The assessment also failed to include the Assistant Director of Nursing (ADON) in the staffing plan, which is a critical oversight in ensuring adequate staffing for resident care. Additionally, the assessment inaccurately identified the managing health care system responsible for evaluating policies and procedures. During an interview, the Administrator acknowledged these deficiencies, stating that the facility assessment was updated quarterly and as needed, but admitted that it was inaccurate and should have included the correct managing health care system, listed the ADON, and provided an accurate acuity of the residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 215 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wareham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sippican Rehabilitation And Healthcare Center | 4.3 mi | ★★★★★ | 4 | 0 |
| Royal Cape Cod Nursing & Rehabilitation Center | 6.3 mi | ★★★★★ | 6 | 0 |
| Bourne Manor Extended Care Facility | 7.9 mi | ★★★★★ | 0 | 0 |
| Nemasket Rehabilitation And Healthcare Center | 9 mi | ★★★★★ | 0 | 0 |
| Royal Megansett Nursing & Rehabilitation | 9.8 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.