Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vantage At Lowell Llc during CMS and state inspections, most recent first.
Medication Labeling, Refrigeration, and Cart Security Deficiencies: Multiple opened inhalers, a nasal spray, and an insulin vial were found undated on medication carts, while unopened insulin was stored outside refrigeration despite manufacturer directions. An unlocked treatment cart was also observed unattended, and staff confirmed that opened inhalers and insulin should be dated, unopened insulin should be refrigerated, and treatment carts should be locked.
Food storage and handling practices were not followed when dietary staff left opened dairy and beverage items undated or beyond the allowed storage time, served milk cartons from a mixed container during tray line, and kept spoiled produce in the refrigerator. Surveyors also observed a dietary employee touch refrigerator surfaces with gloved hands and then handle ready-to-eat French toast directly without changing gloves.
Resident privacy was not protected on the Right Unit when an RN was observed using a personal cellphone during med pass and speaking about a nearby resident while on the call. In addition, a nurse left a cart computer screen open multiple times while delivering meds, leaving resident health care information visible to anyone walking by; the DON stated nurses should not be on the phone during med pass and screens should be closed when unattended.
Failure to Follow Wound Offloading and Air Mattress Orders: Two residents with right foot wounds were observed lying in bed with the affected foot or heel directly on the mattress despite physician orders for offloading boots/shoes. Another resident with a history of skin breakdown and pressure injury risk was repeatedly observed on an air mattress set to 250 pounds, although the physician order specified a setting of 200 pounds. Nursing staff and the DON acknowledged the orders were not being followed as written.
Failure to assist a resident with denture and oral care. A resident with severe cognitive impairment, no natural teeth, and a care plan requiring staff cues and assistance was repeatedly observed without dentures, including during meals. The resident stated staff did not help with oral care or offer to place the dentures in, while the DON said staff should have assisted and documented any refusal.
A resident with CHF, COPD, and HTN had a significant 12% weight gain over about 3 months, but the weight change was not identified in nursing notes and the dietitian and physician were not notified. The physician’s note did not address the gain, and the resident was not evaluated by nutrition until about a month later; a later note documented CHF exacerbation with pleural effusion and an increased diuretic dose.
Failure to Maintain PICC Dressing and Required Measurements: A resident with osteomyelitis and IV antibiotics had an undated PICC dressing on the arm, and the TAR did not show weekly dressing changes or required arm circumference/external catheter measurements. Staff stated PICC dressings should be changed after admission and every 7 days, dated, and measured, but the DON said the orders fell off after a hospital transfer.
A resident with anxiety, depression, delirium, and cognitive impairment developed worsening hallucinations and behavioral changes, but behavioral health follow-up did not occur after an initial consult. The record showed recommended psych med changes and a 1-4 week follow-up that were not implemented, while staff documented hallucinations, agitation, and punching staff without timely psych referral or physician notification. The resident was later hospitalized for hallucinations requiring psychotropic med adjustment.
Opened Insulin Emergency Kit Not Documented or Replaced: An insulin emergency kit in the medication room refrigerator was found opened with contents removed, but there was no documentation showing what was taken, when it was taken, or who removed it. Staff stated the nurse opening the kit should have completed the form in the kit and faxed it to the pharmacy for a replacement, but there was no way to confirm that a replacement had been ordered.
Medication Given Outside Ordered Blood Pressure Parameters: A resident admitted with orthostatic hypotension received midodrine despite a physician order to hold the medication when SBP was greater than 130. The MAR showed multiple administrations outside the ordered parameters, and both the UM and DON acknowledged that nursing should have followed the BP hold instructions.
The facility failed to keep accurate and complete records for two residents with wound care orders and one resident with behavior monitoring needs. Two residents with right foot/heel wounds were observed in bed without the ordered offloading devices in place, yet the TAR showed the wound care orders as complete. For another resident with delirium, anxiety, depression, and moderate cognitive impairment, behavior monitoring was not documented on every shift, with gaps noted in the CNA documentation record.
QAPI monitoring was ineffective because a falls assessment project was started but not clearly followed up in monthly QAPI meetings, and no performance measures or audit notes were available. Residents also reported that food was consistently served cold, with council minutes showing ongoing complaints about tray and coffee temperatures; the DON/Administrator said the issue remained unresolved and that temperature checks were limited to only one item on the tray, usually the meat.
A facility failed to implement enhanced barrier precautions for two residents. One resident with chronic buttock wounds and another resident with an indwelling urinary catheter both had care plans and Kardex instructions requiring gowns and gloves for high-contact care, but staff were observed providing wound care and a bed bath while wearing gloves only. Interviews showed staff and nursing leadership acknowledged the gown requirement, and one nurse was unaware of enhanced barrier precautions and believed universal precautions applied instead.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A staff member was observed texting on her cell phone instead of assisting a resident with severe cognitive impairment and total dependence during breakfast, resulting in the resident being left unattended with untouched food. This incident, along with ongoing concerns about staff phone use noted in Resident Council Minutes, demonstrates a failure to ensure a dignified dining experience as required by facility policy.
Two residents at high risk for pressure ulcers did not have their air mattresses set according to physician orders or their actual weights. One resident with a stage 4 ulcer had the mattress set too low, while another resident's mattress was set excessively high. Staff interviews confirmed that mattress settings were not checked as required, and physician orders were not followed.
A resident with severe cognitive impairment and upper extremity limitations did not receive recommended OT services or a hand orthotic after transitioning to hospice care. Despite documented recommendations for splinting to address hand contracture, no device was provided, and the care plan lacked interventions for therapy or orthotics. Staff interviews confirmed a lack of coordination and follow-through with therapy recommendations.
A resident with multiple comorbidities experienced a severe and rapid weight loss that was not evaluated by the RD as required by facility policy. Despite documented significant weight loss, no new nutritional assessment or dietary interventions were implemented in a timely manner, and staff interviews confirmed that the deficiency was not addressed until months later.
A Laboratory Technician failed to follow infection control protocols by placing a supply and specimen bag, which is used in multiple facilities and contacts the floor, directly on a resident's bed in a room under enhanced barrier precautions. The technician then performed a blood draw and handled paperwork using surfaces in the room, actions confirmed by staff interviews to be inconsistent with required infection prevention standards.
Residents reported not receiving personal mail deliveries on Saturdays, as confirmed during a group meeting and by review of the posted activity calendar, which specified mail distribution only from Monday to Friday. The Administrator was unaware of this limitation until it was brought to his attention.
The facility failed to ensure that treatment carts on two units were locked and secured while not in use. The policy indicates that medications should be stored securely and only accessible to authorized personnel. However, treatment carts were observed unlocked and unsupervised on multiple occasions. Interviews confirmed that the expectation is for carts to be locked unless a nurse is present.
The facility failed to ensure that foods provided to residents were prepared in a manner that conserved nutritional value, flavor, and were served at appetizing temperatures. Numerous residents expressed concerns about the poor quality, palatability, and temperature of the food. Test trays revealed that the food was often served at inappropriate temperatures and lacked flavor. Staff members, including the Activity Director, Nursing Supervisor, Foodservice Director, and DON, confirmed awareness of the residents' complaints.
The facility failed to properly store food items and follow sanitation and food handling practices, leading to a risk of foodborne illness. Observations included improperly labeled and decaying food in the walk-in refrigerator, and multiple instances of staff not following proper hand hygiene and food handling protocols.
The facility failed to provide a dignified dining experience for residents on the Right Wing unit. CNAs were observed feeding residents in bed while standing over them and there were significant delays in serving meals to residents sitting at the same table. These actions were confirmed by the Nursing Supervisor and the DON.
A resident was subjected to verbal and mental abuse by an OT, who loudly and sternly instructed the resident in the presence of others, leaving the resident visibly upset and embarrassed. Despite the presence of other staff, no one intervened during the incident.
The facility failed to ensure that a resident was free from restraints by locking the bed remote, preventing the resident from repositioning themselves. Despite the resident's moderate cognitive impairment and dependence on staff, the bed remote was locked without proper assessment or documentation, leading to the deficiency.
The facility failed to ensure staff followed its abuse policies and procedures when an OT yelled at a resident with a history of cerebral infarction and dementia. Despite the presence of other staff, no one intervened or checked on the resident, leading to the resident feeling upset and embarrassed.
The facility failed to report an allegation of neglect to the state agency as required. A grievance indicated that a family member found a resident without oxygen, resulting in an oxygen saturation level of 81 percent. The Director of Nursing was unsure if the incident was reported to the state agency.
The facility failed to implement resident-centered care plans and aspiration precautions for three residents, leading to unsupervised meals and inappropriate dietary modifications. Despite clear physician orders and care plans, residents with severe cognitive impairments and aspiration risks were left unsupervised and given incorrect food textures, resulting in multiple coughing episodes. Staff interviews revealed gaps in following care cards and communication regarding dietary needs.
The facility failed to provide scheduled showers for a resident with moderate cognitive impairment and heart failure, who had not received a shower in 40 days despite being scheduled for weekly showers. Staff interviews and documentation confirmed the deficiency.
The facility failed to follow up on a resident's and physician's request to schedule an appointment for glasses. Despite multiple documented requests and the resident expressing difficulty in seeing, the resident was not scheduled to be seen by the eye doctor. Both the Nursing Supervisor and the DON confirmed that the resident's request was missed.
The facility failed to assess the necessity of an indwelling catheter for a resident admitted with urinary retention. Despite hospital recommendations for a voiding trial, the facility did not conduct the trial, and the resident's medical history did not justify the continued use of the catheter. The DON acknowledged the oversight.
A resident with severe cognitive impairment experienced a significant weight loss that was not addressed in a timely manner. Despite the facility's policy requiring immediate action for significant weight changes, the resident's weight loss was not managed until over two months later, when a nutrition assessment was conducted, and a supplement was recommended.
The facility failed to follow physician's orders for a resident's oxygen therapy, providing an incorrect flow rate and not cleaning the external filter on the oxygen concentrator as required. The resident, with chronic heart failure, type 2 diabetes, and pneumonia, was observed receiving oxygen at 1.5 liters instead of the prescribed 3 liters, and the filter was visibly dusty.
The facility failed to provide the correct diet texture for three residents, including serving ground meat instead of pureed meat and allowing a resident to consume non-pureed food items brought by family members. The Nursing Supervisor, Speech Therapist, and DON confirmed the deficiencies.
A resident with multiple sclerosis and a BIMS score of 14 developed a stage 2 pressure wound on the right buttock, which was not documented in the skin assessment. Interviews confirmed that all skin issues should be included in weekly assessments, making the omission an inaccuracy.
Medication Labeling, Refrigeration, and Cart Security Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with State and Federal requirements. During observation of the left-wing B-side medication cart, multiple opened inhalers and a nasal spray were found undated, including budesonide formoterol, Bevespi glycopyrrolate and formoterol, Anoro Ellipta, Qvar Redihaler, Symbicort, and fluticasone propionate nasal spray. The same cart also contained unopened Humalog KwikPen insulin and unopened Novolog insulin that were not refrigerated, despite manufacturer directions to keep unopened insulin refrigerated until ready to use. A separate observation of the right-wing A-side medication cart found an opened Lantus insulin vial that was undated, an unopened Lantus insulin pen that was not refrigerated, and opened inhalers including Trilegy Ellipta and budesonide and formoterol that were also undated. In addition, the right-wing treatment cart was observed unlocked and unattended. Staff interviews confirmed that inhalers and insulin should be dated when opened, unopened insulin should be refrigerated, and treatment carts should be locked when not in use.
Food Storage and Glove Handling Failures
Penalty
Summary
The facility failed to store, label, date, and discard food in accordance with professional food safety standards. During an initial kitchen observation, surveyors found an opened container of cottage cheese with an opened date of 5/21/26, two crates of half-pint fat-free milk cartons dated 5/31/26, an opened 46-ounce carton of orange juice labeled with an opened date of 5/24/26, and produce in the walk-in refrigerator that showed significant signs of decomposition. The tomatoes had textural and color changes with fuzzy black, white, and/or green growth resembling mold and a milky liquid underneath, and the green peppers had textural changes with a dark green liquid underneath them. During tray line service at breakfast, surveyors observed half-pint fat-free milk cartons dated 5/31/26 mixed with whole milk cartons in a black container with ice next to the tray line. The Food Service Director was observed taking milk cartons from that container and placing them on resident trays for service. On a later follow-up visit, the opened cottage cheese remained in the refrigerator with the same opened date, and the moldy tomatoes and decomposed peppers were still present in the walk-in refrigerator. In the nourishment kitchens, surveyors also found opened beverages without opened dates, including nectar-thick orange juice, nectar-thick lemon-flavored water, a nectar-thick dairy drink, and cranberry juice cocktail, despite manufacturer instructions on some items to discard within a specified number of days after opening. The facility also failed to prevent potentially contaminated glove use during food service. During breakfast tray line service, a dietary employee touched the refrigerator handle and door with gloved hands, handled fruit cocktail, returned it to the refrigerator without changing gloves, and then continued assembling hot breakfast plates. The employee then handled ready-to-eat French toast directly with the same gloves. The employee stated she should have changed gloves after touching the refrigerator door and before handling the French toast, but did not. The Food Service Director and Corporate District Manager stated dietary staff should not touch food directly and should change gloves after potential contamination, including contact with refrigerator doors and handles.
Resident Privacy Not Protected During Medication Pass and at Nursing Carts
Penalty
Summary
The facility failed to protect resident privacy on one of two units by allowing nursing staff to use personal cellphones during medication pass and by leaving computer screens displaying resident health care information unattended. The facility’s policies titled Release of Information and Electronic Medical Records did not include procedures or guidelines related to staff taking personal calls during medication pass or securing and locking computer screens while unattended. On 6/4/26 at 1:00 P.M., a surveyor observed Nurse #5 at the medication cart on the Right Unit preparing medications with her phone standing vertically on the cart in front of a cup of medications. A resident nearby was speaking to Nurse #5, and Nurse #5 stated, “oh that’s just my old guy/girl.” When the surveyor asked if Nurse #5 was on her phone, Nurse #5 responded, “that’s okay,” then later said, “I’ll call you back,” and hung up the phone. During interview, the DON stated nurses should not be on the phone while performing medication pass and should not speak about residents while on a personal call. On 6/1/26, Nurse #1 left her nursing cart multiple times to deliver medications to a resident room, and each time the computer screen was left open with resident health care information visible to anyone walking by. The DON stated computer screens at the nursing carts should be closed when nursing is not present to ensure patient confidentiality.
Failure to Follow Wound Offloading and Air Mattress Orders
Penalty
Summary
The facility failed to ensure physician orders were implemented for two residents with wounds on their right foot. Resident #6, who had paraplegia, diabetes, and a chronic non-pressure ulcer of the right foot, was observed lying in bed with the right foot directly on the bed on multiple occasions. The resident had a physician order to keep pressure off the right lateral foot and apply an off-loading air boot when in bed, but staff had not implemented the order. A nurse reviewed the order and stated the resident’s foot should never be directly on the bed and that the order had not been implemented by staff. Resident #17, who had polyneuropathy and chronic kidney disease, was also observed lying in bed with the right heel directly on the bed on multiple occasions. The resident had a physician order for the right heel wound that included applying an offloading shoe/boot. A nurse reviewed the order and stated the resident’s foot should never be directly on the bed and that the order had not been implemented by staff. Resident #78, who had multiple sclerosis, chronic pain syndrome, type 2 diabetes with polyneuropathy, and was at risk for pressure ulcers/injuries, was observed lying in bed on an air mattress repeatedly set to 250 pounds. The physician order specified an alternating pressure air mattress setting of 200 pounds, and the altered skin care plan included setting the air mattress per order. Nursing staff and the DON acknowledged the mattress should have been set to 200 pounds as ordered, but it remained at 250 pounds during the observations.
Failure to Assist Resident With Denture and Oral Care
Penalty
Summary
The facility failed to provide assistance with oral care, specifically assistance with dentures, for one resident who had severe cognitive impairment and no natural teeth. The resident’s MDS indicated a BIMS score of 5 out of 15 and that supervision was required for oral care. The resident’s care plan and Kardex both indicated that staff were to provide cues and assistance with personal hygiene and oral care, and the facility policy directed that denture care be provided before breakfast and at bedtime, with assistance as needed to keep dentures in the mouth as much as possible. During observations and interviews, the resident was seen in bed without dentures and stated that staff had not assisted with oral care or offered to place the dentures in before meals, although the resident wanted to wear them. The resident’s dental record noted that dentures were present and that assistance was needed with placing them in the mouth and with daily oral care. A CNA stated she had never seen the resident wear dentures and that denture assistance is part of daily care, while the DON stated staff should have placed the dentures before meals and expected a refusal note if the resident declined. On a later observation, the resident again ate breakfast without dentures, and a CNA responsible for the resident that day said she did not offer to place the dentures in before breakfast.
Failure to Identify and Address Significant Weight Gain in a Resident with CHF
Penalty
Summary
The facility failed to identify and address a significant weight gain for one resident with congestive heart failure (CHF). The resident was admitted with diagnoses including CHF, chronic obstructive pulmonary disease, and hypertension, and had intact cognition per the MDS. The care plan identified the resident as being at risk for respiratory distress and noted monitoring for signs and symptoms of CHF, including weight gain unrelated to intake, as well as a nutrition-related risk related to a history of atrial fibrillation, hypertension, heart disease, and CHF. The resident’s recorded weights showed a gain from 189.3 lbs to 215.6 lbs over about three months, a 26.3 lb increase and a 12% significant weight gain. The record did not show that the dietitian or physician was notified of the weight gain, and nursing progress notes did not identify it. The physician’s progress note dated 2/16/26 did not address the weight gain. A later physician note documented CHF exacerbation with pleural effusion and an increase in diuretic medication from 20 mg to 40 mg. Nutrition progress notes showed the resident was not evaluated for the significant weight gain until one month after it was identified. During interviews, the dietitian stated residents with weight changes over 5% in a month should be seen within 3-5 days and that CHF residents on diuretics should be evaluated sooner than one month; the DON stated the resident should have been seen within the week of a significant weight change, especially with CHF.
Failure to Maintain PICC Dressing and Required Measurements
Penalty
Summary
The facility failed to provide care and maintenance of a PICC line consistent with professional standards of practice for one resident. Resident #84 was admitted with diagnoses including acute osteomyelitis of the right ankle and foot, had a BIMS score of 15 out of 15, and was receiving IV medications. On 6/1/26, the resident was observed in bed with a PICC dressing on the left arm that was undated, and the resident stated antibiotics were being given three times a day for a foot infection and that the dressing had been changed a few days earlier. The resident’s physician’s order, initiated 5/6/26, directed weekly PICC dressing changes and measurement of arm circumference and external catheter with each dressing change, but the order was discontinued the next day. Review of the TAR from 5/8/26 to 5/28/26 did not show that the PICC dressing had been changed or that arm circumference and external catheter measurements had been recorded. Staff interviews indicated the dressing should be changed 24 hours after admission and every seven days, dated when changed, and accompanied by arm circumference and external catheter measurements. The DON stated the resident had been sent out to the hospital and upon return the PICC dressing change orders fell off.
Failure to Provide Behavioral Health Follow-Up for Resident With Hallucinations
Penalty
Summary
The facility failed to provide necessary behavioral health services for one resident with diagnoses including delirium, anxiety, and depression, who also had moderate cognitive impairment with a BIMS score of 10. The resident reported anxiety, depression, and new hallucinations that had led to a recent hospitalization, and the resident stated behavioral health services had been seen only once in July 2025 without further follow-up. The resident and the health care proxy both said they wanted continued behavioral health involvement for mental health concerns. The record showed a behavioral health note from July 2025 for increased anxiety, depression, and restlessness, with recommendations to increase sertraline, start buspirone, discontinue trazodone, and follow up in 1 to 4 weeks. The medical record did not show that the follow-up occurred or that the medication recommendations were implemented. Later documentation included resident council minutes noting the resident reported seeing a child in the room next to hers/his, and a nursing progress note describing the resident as acting strangely, kicking, punching staff, and being unable to redirect. The record did not show that the physician was notified of the new behavior or that behavioral health services were contacted at that time. Additional documentation showed ongoing hallucinations and discussion at a care plan meeting that the resident had a history of visual hallucinations and seeing people in the bathroom, with agreement for psych follow-up and consent for behavioral health in the chart. The record did not show that a referral was made after that meeting before the resident’s hospitalization. Staff interviews indicated the resident had worsening visual and auditory hallucinations, including seeing a child under a roommate’s bed and a man in the room, along with increased behaviors such as attempting to hit staff. Multiple staff members stated there had been a lapse in behavioral health coverage, poor communication, and incomplete documentation, and the resident was later hospitalized for hallucinations requiring psychotropic medication adjustment.
Opened Insulin Emergency Kit Not Documented or Replaced
Penalty
Summary
Pharmaceutical services failed to meet the needs of each resident when an insulin emergency kit in the left-wing medication room refrigerator was found opened with some contents removed, and there was no documentation showing what had been removed, when it was removed, or who removed it. The facility policy titled "Emergency Pharmacy Service And Emergency Kits" stated that when medication is used from an emergency kit, the nurse must record the medication on the medication order/use form and call the pharmacy for replacement or flag the kit for replacement as soon as possible after administration. During the inspection, the opened insulin kit had no documentation indicating whether the removed item was Lantus insulin or whether the pharmacy had been notified for a replacement. Nurse #3 stated the nurse who opened the kit should have documented the paperwork in the kit and faxed it to the pharmacy, Unit Manager #1 stated the nurse should document what was taken and fax it to the pharmacy, and the DON stated the nurse opening the kit should complete the form in the kit and fax it to the pharmacy for a replacement kit.
Medication Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure that one resident was free from significant medication errors when nursing did not hold midodrine in accordance with the physician’s order. Resident #58 was admitted in March 2026 with diagnoses including orthostatic hypotension and was cognitively intact, with a Brief Interview for Mental Status score of 15 out of 15 on the 4/17/26 MDS. The physician’s order dated 4/21/26 directed midodrine HCL 2.5 mg by mouth twice daily for hypotension and to hold the medication if systolic blood pressure was greater than 130. Review of the MAR showed that midodrine was administered on multiple occasions despite blood pressure readings above the ordered hold parameter, including readings of 138/70, 154/88, 132/74, 132/78, 132/70, 132/74, 132/72, 136/77, 138/76, 132/75, and 134/66. During interview, the Unit Manager stated that the resident’s midodrine order had parameters that nursing should follow and that the medication should be held if systolic blood pressure was greater than 130. The DON also stated that nurses should follow physician’s blood pressure parameters and medication should not be administered outside those parameters.
Incomplete and inaccurate resident documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Residents #6 and #17 by documenting physician-ordered wound care as completed when the ordered interventions were not observed being carried out. Resident #6 was admitted with paraplegia, diabetes, and a chronic non-pressure ulcer of the right foot, and was observed on multiple occasions lying in bed with the right foot directly on the bed and not offloaded from pressure. Resident #17 was admitted with polyneuropathy and chronic kidney disease, and was also observed on multiple occasions lying in bed with the right heel directly on the bed. Both residents had physician orders to keep pressure off the wound and to apply an offloading boot or shoe when in bed, yet the Treatment Administration Report documented the orders as complete. The DON stated that orders should only be marked complete if actually done and that otherwise the record would be inaccurate. The facility also failed to ensure behavior monitoring documentation was completed every shift for Resident #45. Resident #45 was admitted with delirium, anxiety, and depression, had moderate cognitive impairment with a BIMS score of 10, and had a history of behaviors including a manic episode with kicking and punching staff, as well as a hospitalization for altered mental status/delirium with worsening hallucinations. Review of the Documentation Survey Report showed behavior monitoring was documented on only 57 of 93 shifts in May 2026 and 6 of 10 shifts in June 2026. A CNA stated that CNAs are responsible for documenting daily care, including behaviors in the electronic medical record, and the DON stated that all medical record documentation should be accurate and complete, including behavior monitoring by CNAs.
QAPI Monitoring Deficiencies for Falls Assessments and Food Temperatures
Penalty
Summary
The facility failed to maintain an effective QAPI plan by not monitoring whether a falls assessment project was being completed and by not consistently tracking the temperature of food served to residents. The facility policy stated that data should be used to monitor policies, performance indicators should be reviewed against benchmarks or targets, and leaders should evaluate the QAPI program on an ongoing basis. The Administrator said a QAPI plan had been initiated in April 2026 for completion of falls assessments throughout the facility, with audits and monthly discussion at QAPI meetings, but he could not say whether the project was reviewed during the May 2026 meeting and could not provide follow-up audits or meeting notes. Corporate Nurse #1, the former DON, said falls assessments were not reviewed during the May monthly meetings and the facility could not provide measures of performance for that QAPI plan. Residents reported that food was consistently served cold, including breakfast meals, and Resident Council minutes documented complaints that food on trays and coffee were often cold. The QAPI plan for food temperatures identified that food temperatures had been below the target range, with a goal that all temperatures be within range. Although tray temperatures were audited weekly through 5/15/26 and May minutes stated food was much improved, later Resident Council minutes still stated that food was not being served at proper temperature and remained inconsistent. The Administrator said the food issue had persisted since the current food service company was put in place, that he did not feel the QAPI had been resolved, and that he was responsible for random temperature audits but was only checking one item on the tray, usually the meat.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain its infection prevention and control program by not implementing enhanced barrier precautions for two residents with conditions requiring those precautions. The facility policy stated that enhanced barrier precautions are used to prevent the spread of MDROs and that gloves and gowns are to be applied before high-contact resident care activities, including bathing/showering, hygiene, and wound care. For one resident, who was admitted with osteoarthritis and diabetes and was cognitively intact with a BIMS score of 14, the care plan for bilateral buttock skin breakdown directed staff to follow enhanced barrier precautions. The resident’s Kardex also indicated to wear a gown when providing wound care. During observation, a nurse cleansed the resident’s bilateral buttock wounds and applied topical cream while wearing gloves only and not a precaution gown, even though a sign for enhanced barrier precautions was posted on the door. The resident, CNA, Infection Control Nurse, and DON all stated that gown and gloves were required for wound care. For the second resident, who was admitted with diabetes and chronic kidney disease and had an indwelling urinary catheter, the care plan identified enhanced barrier precautions due to the Foley catheter. The Kardex directed staff to wear gowns for activities including bathing/showering, hygiene, toileting, and incontinent care. During observation, a CNA provided a bed bath while wearing gloves but not a precaution gown, and there was no sign or PPE cart outside the room. Interviews showed staff confusion about the precautions, including one CNA who was unaware of the requirement and a nurse who said she had never heard of enhanced barrier precautions and believed the resident was on universal precautions instead.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Staff Use of Cell Phone During Resident Feeding Compromises Dignity
Penalty
Summary
A deficiency occurred when staff failed to treat a resident in a dignified manner during the dining experience. Specifically, a staff member was observed using her cell phone to text while she was supposed to be assisting a resident with eating breakfast. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living including eating, was left unattended with food untouched while the staff member continued to use her phone for at least ten minutes. The incident was directly observed by a surveyor and corroborated by a report from the facility's Ombudsman, who had previously witnessed similar behavior. Facility records, including Resident Council Minutes, indicated that staff use of cell phones and headphones while working had been an ongoing concern among residents, despite some reported improvement. Interviews with facility leadership confirmed that the staff member involved was a hospice CNA from an outside agency, but both the Unit Manager and the DON stated that all staff, including outside agency personnel, are expected to follow facility policies and provide a dignified dining experience. The facility's policy requires that residents be treated with dignity and respect at all times.
Failure to Ensure Correct Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice, specifically regarding the correct setting of air mattresses according to physician orders. For one resident with a stage 4 sacral pressure ulcer, severe cognitive impairment, and high risk for developing further ulcers, the air mattress was repeatedly observed set at the lowest setting (50 lbs), despite a physician order for a setting of 150 and a recent weight of 91.5 lbs. Multiple staff interviews confirmed that the mattress setting was too low and not in accordance with the physician's order or the resident's weight, and that this could affect skin integrity. Another resident, also severely cognitively impaired and dependent for positioning, was observed with an air mattress set at 380 lbs, while the physician's order specified a setting of 150 and the resident weighed less than 100 lbs. Staff interviews revealed that the mattress setting was not checked as required each shift, and the DON confirmed that physician orders for mattress settings were not followed. These failures were observed over multiple shifts and confirmed by staff, indicating a lack of adherence to established protocols for pressure ulcer prevention and care.
Failure to Provide Recommended Occupational Therapy and Hand Orthotic for Resident on Hospice
Penalty
Summary
The facility failed to provide continued Occupational Therapy (OT) services as recommended for a resident with significant upper extremity impairment and severe cognitive impairment. The resident, who had diagnoses including Parkinsonism, a stage 4 pressure ulcer, and malnutrition, was dependent on staff for all activities of daily living and had a clenched left hand with limited range of motion. Observations over multiple days confirmed that no hand orthotic or splinting device was in use, despite recommendations from the OT and Nurse Practitioner for splinting to address the resident's hand positioning and stiffness. Documentation showed that the resident was referred to OT for assessment and splinting due to increased tightness and limited range of motion in the left hand. The OT evaluation confirmed the need for splinting and recommended continued OT services. However, after the resident was admitted to hospice care, OT services were discontinued, and the care plan did not include any interventions for hand orthotics or therapy. Interviews with staff revealed a lack of awareness and follow-through regarding the OT recommendations, with both the Director of Rehab and the DON acknowledging that coordination with hospice and implementation of therapy recommendations did not occur as required. The facility's policy required therapy services to be scheduled and coordinated according to the resident's treatment plan, with nursing responsible for implementing therapy recommendations. Despite these requirements, the resident did not receive the recommended OT services or hand orthotic, and there was no documentation or evidence of a care plan addressing these needs during the survey period.
Failure to Assess and Intervene After Severe Weight Loss
Penalty
Summary
The facility failed to ensure that nutritional practices were implemented in accordance with professional standards of care for a resident who was at nutritional risk. The resident, who had a history of Parkinson's disease, dementia, and depression, experienced a severe and rapid weight loss that was not evaluated by the registered dietitian as required by facility policy. The policy specified that any significant weight change, such as a loss of 5% or more in one month, should prompt immediate notification to the dietitian and a reassessment of the resident's nutritional status. The resident's weight dropped from 166 pounds to 144 pounds within 19 days, representing a 13.25% loss of total body weight, which met the facility's criteria for severe weight loss. Despite this significant change, there was no documentation of a new nutritional assessment or updated dietary orders in the medical record following the weight loss. The only dietary interventions noted were supplements that had been ordered prior to the weight loss event, and no new interventions were implemented until several months later. Observations and interviews confirmed that the resident required assistance with eating and had a mechanically altered diet, but the severe weight loss was not addressed in a timely manner by the dietitian. Interviews with facility staff, including the unit manager, registered dietitian, and DON, revealed that while the resident was discussed in risk meetings and monitored for weight loss, the registered dietitian did not conduct a reassessment or document an evaluation after the severe weight loss occurred. The dietitian acknowledged that she should have performed a thorough review of the resident's nutritional status at that time, regardless of the resident's hospice status. The lack of timely assessment and intervention following the significant weight loss constituted a failure to provide adequate nutrition and hydration to maintain the resident's health.
Failure to Follow Infection Control Practices by Laboratory Technician
Penalty
Summary
A Laboratory Technician providing services to residents failed to adhere to infection control practices during a blood draw. The technician placed her supply and specimen bag, which is used in multiple facilities and regularly contacts the floor, directly on top of a resident's bed and in contact with the linen. This occurred in a room marked for enhanced barrier precautions and occupied by two residents. The technician proceeded to perform a blood draw for one resident, used the bedside table of the other resident to complete paperwork, and then placed the specimen into the same bag that had been on the bed. Interviews with the Laboratory Technician, a nurse, the unit manager, and the Infection Preventionist confirmed that the technician was expected to follow infection control protocols, including not placing potentially contaminated items on resident beds or linens. The technician acknowledged her actions, stating the bag had fallen off the counter, and demonstrated that the bag is wheeled on the floor between facilities. Facility staff confirmed that this practice was not in line with infection control expectations.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their personal mail deliveries on Saturdays. During a resident group meeting attended by twelve residents, multiple individuals reported that mail was not delivered on Saturdays, and some expressed that they were expecting mail deliveries. Residents indicated that this information was posted on the bulletin board. Upon review, the activity calendar on the bulletin board stated that personal mail would be distributed Monday through Friday only. In an interview, the Administrator confirmed he was unaware that the calendar excluded Saturday mail delivery and acknowledged that this was not correct.
Failure to Secure Treatment Carts
Penalty
Summary
The facility failed to ensure that treatment carts on two units were locked and secured while not in use. The facility's policy on the storage of medications indicates that medications and biologicals should be stored safely, securely, and properly, and should only be accessible to licensed nursing staff, pharmacy personnel, or staff members authorized to administer medications. However, on two consecutive days, the surveyor observed the treatment cart on the Left Unit unlocked and unsupervised in the hallway. Additionally, the treatment cart on the Right Unit was also observed unlocked and unsupervised. During interviews, both a nurse and the Director of Nurses confirmed that the expectation is for treatment carts to be locked unless a nurse is present at the cart.
Food Quality and Temperature Deficiency
Penalty
Summary
The facility failed to ensure that foods provided to residents were prepared in a manner that conserved nutritional value, flavor, and were served at appetizing temperatures. During the survey, numerous residents expressed concerns about the poor quality, palatability, and temperature of the food. At a resident group meeting, all eight participating residents described the food as gross or disgusting. The grievances book also contained two resident grievances regarding food quality, delivery, and accurate meal orders. Test trays revealed that the food was often served at inappropriate temperatures and lacked flavor, with items such as pureed chicken, vegetables, and mashed potatoes being warm but not hot, and milk and juice being slightly warm instead of cold. Additionally, the macaroni and cheese and mixed vegetables were described as bland and mushy, and the pineapple had a canned, metallic taste. Interviews with staff members, including the Activity Director, Nursing Supervisor, Foodservice Director, and Director of Nursing (DON), confirmed that they were aware of the residents' complaints about the food quality and temperature. The Activity Director mentioned that residents regularly report concerns about the food during resident council meetings. The Nursing Supervisor and Foodservice Director acknowledged hearing frequent complaints from residents about the poor quality and temperature of the food. The DON admitted that the food was not good and that efforts were being made to improve its palatability for the residents.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to properly store food items and follow sanitation and food handling practices, leading to a risk of foodborne illness. During an initial walk-through of the kitchen, the surveyor observed several issues in the walk-in refrigerator, including raw chicken covered in slimy, pink juices, a cooked meat product without a date or label, cooked bacon with two different dates, pasta salad with an outdated label, and decaying raw mushrooms. These observations indicate non-compliance with the facility's policy on food receiving and storage, which requires all foods to be covered, labeled, and dated, and for storage areas to be maintained clean at all times. Additionally, during a follow-up visit to the kitchen, the surveyor noted multiple instances of improper hand hygiene and food handling practices. Diet aides were observed putting on new gloves without washing their hands, handling food and utensils with bare hands, and using improper techniques to scoop ice. The Foodservice Director confirmed that staff should wash their hands before putting on gloves and use utensils instead of directly touching food. The director also acknowledged that expired food should have been discarded, as per the facility's policy.
Failure to Provide a Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents on the Right Wing unit. On multiple occasions, CNAs were observed feeding residents in bed while standing over them, rather than sitting at eye level. Additionally, there were significant delays in serving meals to residents sitting at the same table, resulting in one resident waiting 55 minutes to receive their meal after another resident had already begun eating. These actions were observed on 5/14/24 and 5/15/24, and were confirmed by interviews with the Nursing Supervisor and the Director of Nursing, who both stated that staff should be sitting at eye level when feeding residents and that residents sitting at the same table should be served at the same time. On 5/15/24, a resident was observed sitting in a Broda chair at a dining room table with another resident who was being assisted with breakfast. A CNA was seen leaning on the resident's Broda chair and talking to another CNA at a different table, delaying assistance with feeding the resident by 14 minutes. These observations indicate a failure to honor the residents' right to a dignified dining experience, as staff did not adhere to proper feeding protocols and did not ensure timely meal service for all residents.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect Resident #54 from verbal and mental abuse by Occupational Therapist (OT) #1. The incident occurred when OT #1 loudly and sternly instructed Resident #54 to 'Pick up your feet!' in the presence of other residents and staff. When Resident #54 stood up in the wheelchair, OT #1 aggressively questioned the resident's actions and continued to yell at them to sit down. This interaction left Resident #54 visibly upset, with a drawn and sad face, and the resident expressed that OT #1 was always mean and yelled at them frequently. Despite the presence of other staff members, no one intervened or checked on Resident #54 during the incident. Resident #54, who was admitted to the facility with diagnoses including cerebral infarction, cognitive communication deficit, and unspecified dementia, was observed to be cognitively intact based on a recent Minimum Data Set Assessment. The incident was witnessed by surveyors and facility staff, and it was reported that OT #1 had been suspended following the interaction. Interviews with the Director of Nursing and Nurse #1 confirmed that OT #1's behavior was inappropriate and upsetting to Resident #54, who felt embarrassed and mistreated.
Failure to Ensure Resident is Free from Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from restraints by locking the remote control for the bed, preventing the resident from repositioning themselves. The facility's policy on physical restraints emphasizes the right of residents to be free from restraints unless necessary for medical treatment, and requires an interdisciplinary assessment and reassessment process. However, the facility did not follow this policy for Resident #13, who was admitted with diagnoses including dementia, diabetes, heart failure, and pulmonary disease. The resident had a moderate cognitive impairment and was dependent on staff for daily tasks. The resident reported feeling stuck in bed and stated that the staff had purposely broken the bed remote to prevent repositioning. The surveyor observed the bed remote locked and out of reach, with no documented safety need or restraint assessment in the resident's medical record. Interviews with facility staff revealed that the bed remote was intentionally locked to prevent the resident from putting the bed in an unsafe position, as the resident was considered a high fall risk. The Nursing Supervisor acknowledged that the resident was cognitively intact and capable of making their own decisions, and recognized that locking the bed remote could be considered a restraint. The Director of Nursing stated that a restraint assessment should be completed whenever a device limits a resident's movement and that the remote should be within reach if the resident is able to use it independently. Despite this, the bed remote for Resident #13 was locked without proper assessment or documentation, leading to the deficiency.
Failure to Follow Abuse Policies and Procedures
Penalty
Summary
The facility failed to ensure staff followed its abuse policies and procedures for one resident. Specifically, staff who were present when an Occupational Therapist (OT) yelled at a resident did not intervene or remove the OT from the unit as required by policy. The incident involved a resident with a history of cerebral infarction, cognitive communication deficit, and unspecified dementia, who was cognitively intact as indicated by a high score on the Brief Interview for Mental Status Exam (BIMS). The OT was observed loudly and sternly instructing the resident to pick up their feet, and when the resident stood up, the OT aggressively questioned their actions and continued to yell at them. The resident appeared sad and embarrassed, expressing that the OT was always mean and yelling at them. Despite the presence of other staff members, including a nurse and a CNA, no one intervened or checked on the resident during the incident. Interviews with staff members confirmed that the OT's behavior was inappropriate and that they should have intervened. The Director of Nursing (DON) confirmed that the OT had been suspended from the building following the incident. The Social Worker also stated that staff should have intervened during the interaction. The failure to follow the facility's abuse policies and procedures resulted in the resident feeling upset and embarrassed, highlighting a significant deficiency in the facility's handling of abuse prevention and intervention.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency as required for one resident out of a total of 22 sampled residents. The facility's Abuse Prohibition policy mandates that the Administrator must notify local law enforcement and the State Survey Agency within two hours of identifying an alleged or suspected incident. A grievance dated 6/13/23 indicated that a family member found the resident in their room without oxygen, resulting in an oxygen saturation level of 81 percent. The family member documented this as neglect. However, a review of the facility's reporting history showed no indication that this allegation was filed with the state agency. During an interview, the Director of Nursing reviewed the grievance and admitted uncertainty about whether the incident was reported to the state agency.
Failure to Implement Resident-Centered Care Plans and Aspiration Precautions
Penalty
Summary
The facility failed to ensure resident-centered care plans were implemented for three residents, leading to a lack of adherence to aspiration risk precautions. Resident #64, who has severe cognitive impairments and is an aspiration risk, was repeatedly observed eating meals without supervision. Despite physician orders and care plans indicating the need for pureed texture and nectar consistency, the resident was given ground meat and left unsupervised, resulting in multiple episodes of coughing and sneezing during meals. Interviews with staff confirmed that the care cards were not being followed as required, and the resident's need for close supervision was not met. Resident #182, diagnosed with pneumonia, type 2 diabetes, and end-stage renal disease, was also observed eating meals alone in bed without supervision. Physician orders and speech therapy evaluations indicated the need for the resident to be out of bed and in a supervised area during meals, with nectar thick liquids and no straws. However, the resident was left unsupervised multiple times, and there was no documentation of the resident refusing supervision. Staff interviews revealed that the care cards were not updated promptly, and the resident's aspiration risk precautions were not followed. Resident #23, who has severe cognitive impairment and a history of cerebrovascular accident with left hemiparesis, was observed being fed with a straw and drinking thick liquids from a cup, contrary to the speech therapy recommendations for nectar thick liquids via spoon only. The resident experienced coughing episodes during meals, indicating a failure to follow the prescribed aspiration precautions. Staff interviews highlighted inconsistencies in following the care plan and communication gaps regarding dietary and feeding adaptations. The Speech Therapist and Director of Nursing emphasized the importance of adhering to aspiration precautions to prevent aspiration pneumonia, but these precautions were not consistently implemented for Resident #23.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers for Resident #62, who was admitted in January 2024 with diagnoses including heart failure. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and required substantial assistance from staff for bathing tasks. Despite this, the resident reported not having received a shower in a long time and expressed a desire for one. The care plan for the resident, last revised in April 2024, indicated assistance with bathing but did not document any refusal of showers. CNA documentation confirmed that the resident's last shower was on April 5, 2024, 40 days prior to the surveyor's observation, and there was no indication of the resident refusing a shower. Interviews with staff, including a nurse, a CNA, and the Director of Nursing (DON), revealed that all residents are scheduled to receive at least one shower a week. However, the DON acknowledged that there have been issues with ensuring residents receive their scheduled showers and accurately documenting when they last had a shower. The DON confirmed the findings from the CNA documentation that Resident #62 had not received a shower since April 5, 2024, highlighting a failure in the facility's adherence to its policy on providing necessary services for activities of daily living, including personal hygiene.
Failure to Provide Vision Services as Requested
Penalty
Summary
The facility failed to provide vision services as requested for one resident out of a total sample of 22 residents. Specifically, the facility did not follow up with the resident's and physician's request to schedule an appointment for glasses. The resident repeatedly expressed the need for glasses during interviews and observations, indicating difficulty in seeing. The resident's physician had noted the need for an ophthalmology consult and the resident's request for glasses in multiple documents, including a comprehensive eye exam and a physician's visit documentation. Despite these documented requests, the resident was not scheduled to be seen by the eye doctor. The Nursing Supervisor confirmed that the resident was not on the list for the upcoming eye doctor appointments and acknowledged that the resident should have been scheduled. The Director of Nursing also confirmed that the resident's request was missed due to a lack of notification from the doctor to the nursing staff, resulting in the resident not receiving the necessary vision services.
Failure to Assess Indwelling Catheter Necessity
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated continued catheter use was necessary. Resident #23, who was admitted with diagnoses including left hemiparesis and acute kidney injury, had an indwelling catheter inserted due to urinary retention. However, the resident's medical history and diagnosis lists did not indicate a diagnosis that justified the continued use of the catheter. The hospital paperwork recommended a voiding trial to possibly remove the catheter, but the facility failed to conduct this trial. During an interview, the Director of Nursing acknowledged that the resident did not have a required diagnosis for the long-term use of a catheter and confirmed that a voiding trial should have been conducted. The facility's policy, according to the Resident Assessment Instrument (RAI), indicated that indwelling catheters should not be used unless there is valid medical justification, and the assessment should include consideration of the risks and benefits, anticipated duration of use, and potential complications. The failure to conduct a voiding trial and assess the necessity of the catheter led to the deficiency identified in the report.
Failure to Address Significant Weight Loss in a Timely Manner
Penalty
Summary
The facility failed to address the nutritional status of a resident in a timely manner, leading to a significant weight loss that was not promptly managed. Resident #19, who has severe cognitive impairment and requires assistance with activities of daily living, experienced a weight loss of 7.72% from January to February. Despite the facility's policy requiring immediate action for significant weight changes, the resident's weight loss was not addressed until over two months later, in April, when a nutrition assessment was finally conducted, and a supplement was recommended. The Registered Dietitian (RD) acknowledged that the resident should have been assessed sooner and that interventions should have been started earlier to combat the weight loss. The RD, who started working at the facility in late March, was still catching up with the residents' nutritional statuses. The delay in addressing the significant weight loss was confirmed during interviews with the Nursing Supervisor and the RD, highlighting a lapse in the facility's adherence to its weight monitoring policy.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for one resident. Specifically, the facility did not follow the physician's orders for Resident #8's oxygen flow rate and did not ensure the external filter on the oxygen concentrator was clean. Resident #8, who was admitted with chronic heart failure, type 2 diabetes mellitus, and pneumonia, was observed on multiple occasions receiving oxygen at an incorrect flow rate of 1.5 liters instead of the prescribed 3 liters. Additionally, the external filter on the oxygen concentrator was visibly covered in white dust, indicating it had not been cleaned as required by the physician's orders and facility policy. During interviews, the Nursing Supervisor confirmed that the oxygen flow rate should have been set to 3 liters and the external filter should be cleaned at least weekly. The Nursing Supervisor corrected the oxygen flow rate and cleaned the filter upon observation. The Director of Nursing also confirmed that physician's orders should be followed for both the oxygen flow rate and the cleaning of the external filter. The failure to adhere to these orders and policies led to the deficiency noted in the report.
Failure to Provide Correct Diet Texture
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of three residents. Resident #64, who has severe cognitive impairments and is at risk for aspiration, was observed with ground meat instead of the prescribed pureed meat. Both the Nursing Supervisor and the Speech Therapist confirmed that the meat was not moist enough to be considered pureed, indicating a failure to adhere to the physician's order for pureed texture and nectar consistency. This issue was acknowledged by the Director of Nursing (DON) as well. Resident #23, who has severe cognitive impairment and requires moderate assistance with eating, was also observed with ground meat instead of pureed meat, and the meat lacked the required gravy. The physician's order for Resident #23 specified pureed texture with added sauces and gravy, which was not followed. The Nursing Supervisor, Speech Therapist, and DON all confirmed that the meat did not meet the required pureed texture. Resident #13, who has moderate cognitive impairment and is dependent on staff for daily tasks, was served ground meat instead of pureed meat and was observed consuming non-pureed food items brought in by family members. The facility's policy requires verification of food texture and restrictions by a licensed nurse or nursing supervisor, which was not done. The Nursing Supervisor and Director of Rehabilitation were unaware of the non-compliant food items, and the DON confirmed that food in a resident's room should match the physician's order. Resident #13 had not received a speech therapy evaluation to reassess the diet texture.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to accurately document a resident's skin assessment. Resident #2, who was admitted in June 2021 with multiple sclerosis, had a BIMS score of 14, indicating cognitive intactness. The resident developed a stage 2 pressure wound on the right buttock on 5/5/24, as documented on 5/7/24 and 5/14/24. However, the skin assessment dated [DATE] did not indicate the presence of this pressure wound. Interviews with Nurse #4 and the Nursing Supervisor confirmed that all skin issues should be documented in weekly skin assessments, and the omission rendered the assessment inaccurate.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lowell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care One At Lowell | 1.6 mi | ★★★★★ | 0 | 0 |
| Regalcare At Lowell | 2.5 mi | ★★★★★ | 21 | 1 |
| Blaire House Of Tewksbury | 2.5 mi | ★★★★★ | 40 | 0 |
| New England Pediatric Care | 2.7 mi | ★★★★★ | 7 | 0 |
| Life Care Center Of Merrimack Valley | 2.8 mi | ★★★★★ | 5 | 0 |
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