Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wedgemere Healthcare during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, major depression, and a history of falling did not have a person-centered Activities Care Plan in place for months after admission. The IDT reviewed the resident's interests, including music, games, TV, family visits, outdoors, horses, and hot cocoa, but the comprehensive care plan did not document an activities plan until the day of survey. The interim AD said the prior AD had left and she created the plan after finding none in the record, while the DON said she was unaware the plan was missing and expected care plans to be completed within 21 days of admission.
Unqualified Activity Director: The facility failed to ensure the activity program was directed by a qualified activities professional. The AD accepted the role and worked full-time but did not have the required certifications, education, or experience, and the personnel file did not show she met the qualifications as a therapeutic recreation specialist, activities professional, or qualified OT/OTA. She reported most of her background was in preschool, had only five months of nursing home activities experience, had no OT oversight, and the Administrator was unaware she lacked the required qualifications until recently.
Resident Council grievances were not addressed or resolved in a timely manner, and the facility did not provide documented responses to repeated concerns raised by residents. Minutes and a resident group meeting showed ongoing complaints about delayed call bell response, staff using cellphones and earbuds, staff being unfriendly and disrespectful, and food and milk temperatures, with residents stating nothing had been done despite repeated discussion. The Activity Director said concerns were only relayed verbally to the Administrator, and the Administrator said he had no reason the issues were not addressed each month.
Baseline care plans were not completed within the required timeframe or shared with residents or representatives for three residents. One resident admitted with a femur fracture and surgical wounds did not have those needs included in the baseline care plan or receive the med list and care plan summary. Another resident with severe cognitive impairment and bilateral LE contractures did not have contractures addressed and did not receive the med list summary. A third resident with type II DM and G-tube status did not have timely baseline or comprehensive care planning for those conditions, and the representative said the care plan summary was not received.
A resident with severe cognitive impairment, dependence for care, lower extremity impairment, chronic pain, and severe left hip arthritis did not have a comprehensive care plan that addressed bilateral LE contractures or ongoing skin integrity needs. Staff, including the UM, SDC, and DON, stated that contracture management, positioning, and skin care should have been included, but the care plan did not reflect those needs and the potential for skin breakdown plan was discontinued.
Failure to provide individualized and Sunday activity programming. A resident with dementia and severely impaired cognition had no recreation-specific care plan, a blank activities intervention, and was observed in bed without stimulation while activities were offered. Staff said they did not know the resident’s interests or how to engage residents who could not join groups. Residents also reported weekends were boring, Sunday activities lacked staff support and materials, and no non-English activity materials were available.
A resident with a G-tube, dysphagia, and severe cognitive impairment had repeated tube blockages requiring multiple hospital transfers and tube replacements. Staff administered numerous crushed meds through the tube, did not obtain liquid formulations, and one nurse tried to clear a clog with ginger ale without a provider order. Interviews confirmed no hands-on competency checks for G-tube care and no documented pharmacy action despite the recurring clogging.
QAPI Program Failed to Address Resident Concerns and Repeated G-Tube Hospitalizations: Resident Council and group feedback showed repeated complaints about long call light wait times and staff not treating residents with respect and dignity, but no documented PIP, analysis, or revised plan was available. A resident with a G-tube was hospitalized four times because the tube was clogged, and facility leadership stated there was no QAPI issue identified for G-tube care or clog prevention.
Guardian consent was used for an antipsychotic order for a resident with dementia even though the court-approved Roger’s Treatment Plan had expired and the record showed no documentation that it was extended. The chart showed Zyprexa was ordered after the expiration, and staff stated the resident should not receive an antipsychotic without an active, updated plan and that a process should be in place to verify guardian authority for psychotropic consent.
Broken Call Bell Not Kept Within Reach A resident with stroke-related right-sided hemiplegia and impaired cognition was repeatedly observed without a functioning call bell within reach. The call light was tied to the right siderail, where the resident could not reach it with the left hand, and the cord was broken with exposed wire and detached from the wall plug. Staff acknowledged the resident needed the device on the left side, but an LPN did not notify Maintenance and no alternative call device was provided.
Damaged Wheelchair Left in Use: A resident with DM2, muscle wasting, and impaired balance used a manual wheelchair that was observed with a torn backrest, exposed hardware, a frayed seat, and cracked armrests exposing foam. The resident said the chair was used daily, was not in good condition, and the armrests pinched at times. Staff interviews showed equipment issues were supposed to be reported, but no work order was found and environmental rounds did not document review of resident assistive devices.
Failure to Invite Resident and Representative to Care Plan Meetings: A resident with dementia was not invited to participate in care plan meetings, and the resident’s representative said she had not been invited to a care conference for months and had not been able to give input into the plan of care. Staff reported confusion about who was responsible for care plan attendance, turnover in the SW role, and inconsistency in the care planning process; the DON could not provide documentation showing that the IDT met with the resident or representative invited.
Failure to implement post-op wound care and monitoring for a resident with a left hip surgical incision. The resident’s hospital discharge instructions for incision care, showering, and infection monitoring were not transcribed into orders, the care plan, the TAR, or the Kardex, and nursing documentation did not accurately describe the incision or include re-admission and weekly skin assessments. The wound was later found to have dehiscence and purulent drainage, and an ortho visit documented a superficial surgical site infection.
A resident with a Stage 3 necrotic sacral pressure injury had a physician order for a sacrum/pelvis x-ray to evaluate for osteomyelitis, but the x-ray was never completed. An RN entered the order into the radiology provider’s portal, but the test was not done before the end of the shift, and there was no documented nursing follow-up to confirm completion or obtain and report results to the practitioner. The DON later learned from the radiology provider that the x-ray had been cancelled due to lack of a credentialed radiologist to read it, and the facility had not been notified of this cancellation, resulting in the ordered diagnostic test not being provided.
A resident who was dependent on staff for most ADLs and had multiple documented pressure injuries to the sacrum and buttocks was inaccurately charted by nursing staff as having intact skin and no pressure injuries on numerous dates, despite pressure ulcer evaluations showing Stage 2 and Stage 3 wounds. Weekly skin assessments also conflicted with wound documentation. Additionally, CNA ADL flow sheets for this resident contained multiple days and shifts with blank entries for all ADL care areas, even though CNAs and the DON stated that ADL care must be documented in the EMR by the end of each shift.
The facility failed to maintain accurate documentation for four residents, leading to deficiencies in MAR and TAR. A resident's MAR showed unsigned entries for medications prescribed for hypertension and diabetes, while another resident's MAR had similar issues for dementia and depression medications. A third resident's TAR lacked documentation for catheter care, and a fourth resident's MAR showed unsigned entries for diabetes medications. Interviews revealed a lack of awareness and understanding of documentation requirements among staff.
A facility failed to maintain an effective infection prevention and control program, leading to deficiencies in the care of three residents. Staff did not adhere to Contact Precautions or Enhanced Barrier Precautions, as evidenced by a nurse entering rooms without PPE and failing to perform hand hygiene. Additionally, a resident's gastrostomy tube equipment was improperly stored, exposing it to potential contaminants. These actions compromised infection control measures and increased the risk of transmission of infections.
The facility failed to maintain a clean and safe smoking area, with cigarette butts scattered in bushes and planters, and improperly maintained ashtrays. A resident noted that wind often blew over ashtrays, while the Maintenance Director reported that residents did not follow disposal instructions. The Administrator was unaware of the issues despite staff supervision.
A facility failed to create a comprehensive care plan for a resident with Diabetes Mellitus, despite the resident's severe cognitive impairment and recent hypoglycemia. The care plan did not address diabetic management, and staff interviews confirmed the absence of necessary monitoring orders and diabetic protocols.
The facility failed to implement physician orders for two residents, leading to deficiencies in care. One resident did not receive recommended eye drops, while another did not have physician-recommended treatments entered into the electronic medical record. The lack of communication and follow-through on physician orders highlights systemic issues in the facility's process for managing medical recommendations.
A resident with hemiplegia following a stroke did not receive necessary adaptive equipment, including an AFO brace and a left arm sling, essential for mobility and shoulder support. Despite physician orders, the resident was observed without these aids, and staff acknowledged the need for a custom AFO but did not arrange for one. The resident reported discomfort with the provided AFOs, and the treatment record inaccurately indicated daily application, highlighting a failure in meeting the resident's equipment needs.
A resident with a G-tube did not receive appropriate care due to errors in enteral feeding management. The facility failed to administer the correct formula, Jevity 1.5, and instead provided Osmolite 1.5, with inconsistent labeling and documentation. Nursing staff admitted to confusion and errors in following physician's orders, and the Director of Nursing confirmed the deficiencies.
Two residents in the facility had unsecured medications in their rooms, contrary to professional principles. One resident, with end-stage renal disease, had a bottle of Tylenol brought in by a friend, while another resident with glaucoma had unsecured eye drops. Neither resident had a Self-Administration of Medications Assessment completed, and staff were unaware of the presence of these medications.
The Facility did not follow its Abuse Policy by failing to conduct a Massachusetts Nurse Aide Registry (NAR) check for a nurse before her employment. The policy requires an NAR check prior to hiring, but documentation for Nurse #1, who started employment, was missing. The Administrator confirmed the requirement but could not provide evidence of compliance.
Missing Person-Centered Activities Care Plan
Penalty
Summary
The Facility failed to ensure Resident #1 had a comprehensive, person-centered care plan with interventions, treatment goals, and outcomes that addressed individual recreational activity needs. Resident #1 was admitted in October 2025 with diagnoses including Alzheimer's disease, major depression, and a history of falling. Review of the medical record from 10/21/25 through 05/11/26 showed no documentation that an Activities Care Plan had been developed and implemented to meet the resident's individual recreational activities of choice and interest during that seven-month period. The resident's care plan meeting form dated 04/29/26 showed that the interdisciplinary team reviewed activities of interest including music, games, television, family visits, outdoors, horses, and hot cocoa. However, the comprehensive care plan did not contain documentation that an activities care plan had been developed and implemented until 05/12/26, seven months after admission. During interview, the interim Activity Director stated the previous Activity Director had left at the end of April 2026, reviewed the resident's assessments and care plans, and found no Activity Care Plan in place; she created the plan on 05/12/26. The DON stated she was not aware the resident did not have an Activities Care Plan and said it was her expectation that comprehensive care plans are created by all disciplines, including activities, within 21 days of admission.
Unqualified Activity Director
Penalty
Summary
The activity program was not directed by a qualified activities professional. Review of the Activity Director’s personnel file showed she was offered and accepted the role in January 2026 and signed the job description on 1/6/26, but the file did not show that she had completed the training and qualifications required for the position. On 4/1/26, the file still did not indicate that she was a qualified therapeutic recreation specialist, an activities professional with two years of experience in a social or recreational program within the last five years with one year full-time in a therapeutic activities program, or a qualified occupational therapist or occupational therapy assistant. During interview, the Activity Director said she started the role in January and worked full-time, but she did not currently hold any certifications or education relevant to the position. She stated most of her career had been in the preschool setting and that she had only worked in the activities department of a nursing home for five months before becoming the facility’s Activity Director. She also said she had not applied for any education or training programs because she was waiting to hear whether the facility would provide financial support, and she had not collaborated with or received oversight from an OT. Rehab Staff #1 said she was the only full-time OT at the facility and had no involvement in the activity program. The Regional Nurse said she would expect the AD to be enrolled in an education or training program, have required oversight, or be fully qualified at hire, and the Administrator said he was unaware until the prior week that the AD did not have the required qualifications.
Resident Council Grievances Not Addressed
Penalty
Summary
The facility failed to ensure grievances raised through the Resident Council were addressed and resolved in a timely manner, and the facility response was not included in the group discussions. Review of the Resident Council policy indicated that resident council members were to meet monthly, department heads were to respond in writing to grievances before the next meeting, and the council could make recommendations regarding resident services. However, review of Resident Council minutes from October 2025 through March 2026 showed repeated concerns about call bell response times, staff using cellphones and earbuds, staff being unfriendly, food arriving cold, milk arriving warm, and staff speaking other languages in common areas, with multiple items repeatedly marked as not resolved or not improved. The minutes showed that concerns were raised month after month, but there was no documentation that the facility followed up on unresolved old business or new business discussed at the meetings. The record review also indicated that no grievances were initiated through the Resident Council process despite concerns being raised each month. There was no Resident Council meeting held in December 2025 or February 2026, and the minutes reflected that the same concerns continued across the meetings that were held. During a Resident Group meeting with 13 residents, all units of the facility were represented. Twelve of 13 residents stated call bells were not answered timely and nothing was being done about it, 12 of 13 residents said staff remained unfriendly and disrespectful, and 12 of 13 residents, including the Resident Council President, reported food arriving cold and milk arriving warm. In interviews, the Activity Director stated she verbally informed the Administrator of the concerns but had never initiated a grievance since being hired, and the Administrator stated he did not have a reason the issues were not addressed each month and expected a response form to be completed and provided to the responsible department head.
Baseline care plans were incomplete and not shared with residents or representatives
Penalty
Summary
The facility failed to ensure baseline care plans were developed within 48 hours of admission to meet residents’ immediate needs and failed to provide residents and/or their representatives with a summary of the baseline care plan and medication list for three residents. The facility’s policy stated that a baseline care plan is developed to meet immediate needs, is to be completed within 48 hours of admission, and that the resident and/or representative will be provided a summary of the baseline care plan. For one resident admitted with a left femur fracture, surgical aftercare, and spastic quadriplegic cerebral palsy, the record showed a femur fracture repaired by surgery, two surgical incisions, and a need for monitoring and wound care to the incision. The baseline care plan did not include the left femur fracture or the two new surgical incisions requiring nursing care, and the physician’s orders did not reflect the incision monitoring and wound care orders from the discharge summary. The initial interdisciplinary care meeting evaluation also did not show that the resident or representative was provided a copy of the medication summary or baseline care plan. For another resident admitted with chronic pain syndrome, severe left hip osteoarthritis, and failure to thrive, the record showed severe cognitive impairment, dependence for care, lower extremity impairment, and bilateral lower extremity contractures. The baseline care plan did not include the bilateral lower extremity contractures, and the 72-hour meeting form did not show that the resident or representative was provided a copy of the medication summary with the baseline care plan. For a third resident admitted with type II diabetes and gastrotomy status, the record did not show baseline care plans in place within 48 hours of admission or comprehensive care plans addressing diabetes or G-tube status, and the resident representative stated she did not receive a copy of the baseline care plan.
Incomplete Care Plan for Contractures and Skin Integrity
Penalty
Summary
The facility failed to develop and implement a person-centered individualized comprehensive care plan for one resident with severe cognitive impairment, dependence for care, lower extremity impairment, and orthopedic conditions. The resident was admitted in April 2025 with diagnoses including chronic pain syndrome, unilateral osteoarthritis of the left hip, and failure to thrive. The MDS assessment dated 2/12/26 indicated a BIMS score of 3 out of 15, the resident was at risk for pressure ulcers, and had impairment of the lower extremities and orthopedic diagnoses. A hospital discharge summary indicated the resident could not walk, had severe progression of left hip arthritis, and had pain. Review of the record showed a nurse's note dated 4/25/25 documented bilateral lower extremity contractures, but the comprehensive care plan did not include contractures. The Potential Alteration in Skin Integrity care plan was resolved in April 2025, and an Actual Alteration in Skin Integrity care plan was developed in April 2025 and resolved in January 2026, leaving the resident without a skin integrity care plan from 1/16/26 through 4/1/26. During interviews, nursing staff, the Unit Manager, the SDC, and the DON stated that contracture management, positioning, and skin care should have been included in the care plan and that the potential for skin breakdown care plan should not have been discontinued.
Failure to Provide Individualized and Sunday Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities designed to meet residents’ interests and support their physical, mental, and psychosocial well-being on all 4 units, including for one sampled resident with dementia. Resident #23 was admitted with diagnoses including dementia, and the most recent MDS indicated severely impaired cognitive function. The resident’s recreation assessment did not result in a recreation-specific care plan, and the care plan contained a blank intervention for resident-specific activities despite a focus on psychosocial well-being related to dementia with agitation. Surveyors observed Resident #23 in bed with eyes open and no stimulation while activities were being offered on multiple occasions. The resident’s representative stated there were rarely activities for people with cognitive impairment and that the resident spent much of the time in the room or in the dining room without meaningful engagement. A CNA said the resident enjoyed music activities but could not recall music activities during the month of March. The Activities Assistant said she did not really know residents who did not attend group activities and did not know how to offer activities to someone who could not participate, and the Activity Director said no care plan had been initiated for the resident’s specific interests and that she was not very familiar with the resident or his/her preferences. The facility also failed to provide a meaningful and engaging activity program on Sundays in March. Residents reported weekends were boring and that there were no activities staff available to provide supplies on Sunday, and there were no materials available in other languages for residents whose primary language was not English. The Activity Director stated she did not have staff available on Sunday, that residents had to be self-sufficient that day, and that there was no way to ensure residents were offered activities because there was no designated Sunday staff. The March calendar listed Sunday activities such as Daily Chronicle, Coffee Social, Religious Service, and Resident Choice, but there was no designated staff responsible for distributing materials, coordinating activities, or assisting residents.
Repeated G-tube clogging with improper medication administration and lack of tube management oversight
Penalty
Summary
The facility failed to provide services in accordance with professional standards for a resident with a G-tube by not maintaining tube patency and not preventing repeated clogging. The resident was admitted with diagnoses including stroke, right-sided hemiplegia/hemiparesis, type 2 diabetes, protein-calorie malnutrition, dysphagia, and gastrostomy status. The MDS indicated the resident was severely cognitively impaired, received enteral feedings for 51% or more of nutritional needs, and was dependent on staff for bathing, dressing, mobility, and toileting. The resident’s orders included continuous Nepro tube feeding, scheduled water flushes, and multiple medications administered through the G-tube, with 16 scheduled pills daily and no liquid formulations. The record showed four hospital transfers for a clogged or blocked G-tube, with the tube replaced each time. The medical record did not show that the facility attempted to request liquid medication formulations. The facility also did not have a policy on general care and management of G-tubes. On the morning of the last transfer, a nurse flushed the tube without difficulty but then could not administer the third medication because the tube became clogged. The nurse attempted to clear the blockage with ginger ale without contacting the provider first and was unsuccessful. The hospital discharge summary documented that the G-tube was clogged with a significant amount of pill fragments and particles and instructed that the tube had been replaced and confirmed in proper placement. Interviews with the SDC, dietitian, physician, pharmacy consultant, and DON confirmed there had been no hands-on competency observations for G-tube management, no awareness of the repeated clogging pattern, and no documented pharmacy recommendations to change medication formulations despite the repeated tube blockages.
QAPI Program Failed to Address Resident Concerns and Repeated G-Tube Hospitalizations
Penalty
Summary
The facility failed to maintain a QAPI program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Resident Council minutes from November 2025 through March 2026 showed repeated resident concerns that call lights were not answered in a timely manner, help or care required long waits, and staff did not treat residents with respect and dignity. In a group meeting with 11 residents, all 11 said call light wait times were too long, all 11 said staff did not treat them with respect and dignity, and 9 described staff as unfriendly. The Activities Director said these concerns were sometimes raised at Resident Council and were verbally reported to the Administrator, who acknowledged the concerns had been present for about five months, that call light wait time was an active QAPI issue, but that no PIP was available for review, no analysis had been completed, and no revised plan had been developed despite ongoing staff education. The facility also failed to identify and address repeated hospitalizations of a resident with a G-tube. The resident, admitted with diagnoses including cerebral infarct and gastrostomy status, was transferred to the hospital four times over a three-month period because the feeding tube was clogged. The SDC stated she was not aware of a pattern and that there was no QAPI related to G-tubes or preventing clogging, despite the multiple hospitalizations. The DON stated the facility should have identified the ongoing issue, reviewed how the tube was clogging to determine root cause, and that no QAPI had been identified for the care and management of residents hospitalized with clogged feeding tubes. The Regional Nurse stated adverse events should be reviewed and root cause identified.
Guardian Consent Used Without Active Court Treatment Plan
Penalty
Summary
The facility failed to ensure the resident representative/guardian was not given authority beyond the extent required by the court to consent to antipsychotic medication for Resident #33. Resident #33 was admitted in January 2026 with a diagnosis of dementia without behavioral disturbance and had a family member appointed as permanent legal guardian. The record showed a court-approved Treatment Plan for antipsychotic use that was set to expire on 1/21/26 unless extended sooner. The medical record showed the guardian signed an informed consent for psychotropic administration for Zyprexa on 2/10/26, and a physician’s order was entered the same day for Zyprexa 2.5 mg. Review of the chart and progress notes did not show any documentation that the facility submitted anything to the court to extend or change the Treatment Plan beyond its expiration date. During interview, the Social Worker stated the resident should not receive an antipsychotic without an active and updated Roger’s Treatment Plan and said there was not an updated plan in progress. The Regional Nurse stated she expected a process to ensure residents with court-appointed legal guardians have authority to consent for antipsychotic use.
Broken Call Bell Not Available to Resident With Right-Sided Paralysis
Penalty
Summary
The facility failed to ensure a resident with right-sided hemiplegia and hemiparesis had a functioning call bell within reach on the resident’s functional side. The resident was admitted with diagnoses including cerebral infarct (stroke), and the MDS indicated severely impaired cognition, impairment on one side of the body for both upper and lower extremities, and dependence for upper body dressing. The care plan identified right-sided hemiplegia, and the resident was observed lying in bed with the call light tied to the right siderail, where the resident could not reach it with the left hand when prompted. During observation, the call light cord was found broken, with exposed wire on the floor and the cord detached from the plug in the wall socket. The device was not functioning, and the resident was repeatedly observed over several days with the broken call light attached to the right siderail while in bed. When the resident was out of bed in a wheelchair, the broken call light remained out of reach and no alternative device was available for the resident to call for assistance. Staff interviews showed awareness that residents are supposed to have a call bell available and in reach, and that Resident #3 would need the device on the left side because the right side was non-functioning. A CNA reported the broken call bell to a nurse, and the nurse attempted to reinsert the cord but stated it was broken and would need Maintenance. The nurse later said he had forgotten to notify Maintenance and did not provide an alternative device, and the Administrator stated that staff should have ensured a functioning call bell was in reach at all times and that this did not occur.
Damaged Wheelchair Left in Use
Penalty
Summary
The facility failed to ensure that Resident #14’s wheelchair was maintained in a clean and safe condition. Resident #14, who was admitted in April 2018 and had diagnoses including type 2 diabetes mellitus and muscle wasting and atrophy, was cognitively intact per the 2/13/26 MDS and used a manual wheelchair for mobility. The care plan identified weakness, decreased strength and endurance, fatigue, muscle weakness, and impaired balance, with wheelchair use listed under locomotion supervision. During observation on 3/26/26, the resident was seen sitting on the bed with the wheelchair beside the bed, and the wheelchair had a torn upper left backrest with a screw and metal washer exposed, a worn and frayed right side of the seat with no vinyl covering and tearing away from the base, and cracked and torn armrests exposing foam underneath. The resident stated the wheelchair was used daily, was not in good condition, and that the cracked armrests pinched the arms at times. The same damaged condition was observed again on 3/27/26 and 3/31/26. Interviews with the Maintenance Director, CNA, Housekeeping Director, DOR, and Administrator showed that staff were expected to report equipment problems, wheelchairs were cleaned monthly, and environmental rounds were completed, but the facility’s TELS work history showed no reported issues for the wheelchair and the monthly environmental rounds from January through March 2026 did not document evaluation of resident assistive devices such as wheelchairs.
Failure to Invite Resident and Representative to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that Resident #23 was invited to participate in the care plan process or that there was a documented rationale for why the resident or resident representative could not practicably participate in development of the care plan. Resident #23 was admitted in April 2024 with diagnoses including dementia. Review of the facility policy stated that the interdisciplinary team is responsible for developing an individualized comprehensive care plan and that the resident, family, and/or legal representative are encouraged to participate in care plan development and revisions. During interview, the resident’s representative stated she had not been invited to a care conference since the fall and had not been able to provide input into the resident’s plan of care. The Activities Director said she had not attended a care plan meeting since her hire in January and was unsure of the process or who was responsible. The Social Worker stated the facility identified on the first day of the recertification survey that care plan invitations were not being sent to residents or resident representatives, and that care plans had been conducted without the interdisciplinary team because it was difficult to identify who was responsible for attending. The DON acknowledged inconsistency in the care planning process, stated there had been turnover in social work staff, and could not provide documentation showing that meetings were held with the interdisciplinary team and that residents or resident representatives were invited. The Regional Nurse stated her expectation was that care plans are interdisciplinary and that residents and families are invited to participate in development and review.
Failure to Implement and Monitor Post-Op Surgical Wound Care
Penalty
Summary
The facility failed to ensure appropriate treatment and care for a resident with post-operative left hip surgical incisions after a femur fracture repair. The resident was admitted with diagnoses including fracture of the left femur, surgical aftercare, and spastic quadriplegic cerebral palsy, and the MDS indicated the resident was cognitively intact, had a surgical wound, and was at risk for pressure ulcers. On admission, the resident refused a skin assessment, and the initial skilled charting documented two surgical incisions with medi-strips, but the documentation did not include the number of medi-strips, the wound/incision lines, or surrounding tissue. The Hospital Discharge Summary included specific post-op instructions for incision monitoring, dressing care, showering, and signs that required provider notification, but the facility failed to transcribe and implement those instructions into physician orders, the care plan, the Kardex, and the TAR. The care plan did not identify the left femur fracture, the two surgical incisions, or the bathing and showering requirements. The Kardex also did not include the specific bathing/showering instructions. The MAR and TAR did not show orders or monitoring for the left hip incisions from admission through the new order entered later for every-shift monitoring of the incision site for signs and symptoms of infection. After the resident returned from the hospital, the record did not show a nursing re-admission evaluation or a skin assessment, and the weekly skin evaluations did not identify the surgical wound. The wound documentation remained unchanged across multiple skilled charting entries and did not describe the current condition of the incision or surrounding tissue. Nursing notes also failed to describe the surgical incisions or indicate that wound physician services had been offered and declined. The wound physician later documented mild dehiscence with purulent drainage and clinical signs of infection in the left hip surgical wound, and the orthopedic visit documented a superficial surgical site infection with erythema and warmth, leading to doxycycline and a CT order. Interviews with nursing leadership and the physician confirmed that the post-op wound care orders, monitoring, documentation, and care planning were expected but were not in place.
Failure to Ensure Completion and Follow-Up of Ordered X-Ray
Penalty
Summary
The facility failed to ensure that a resident received radiology services as ordered by the physician. A physician progress note dated 12/07/25 documented that the resident had a Stage 3 sacral pressure injury that appeared necrotic, and the physician ordered an x-ray of the sacrum and pelvis to evaluate for osteomyelitis. A corresponding physician order dated 12/07/25 directed staff to obtain an x-ray of the pelvis and sacrum. Review of the medical record from 12/07/25 through 12/15/25, when the resident was transferred to the hospital for evaluation, showed no documentation that the ordered x-ray had been completed. Nurse #2 reported that the physician saw the resident late in the evening on 12/07/25 and ordered the sacrum and pelvis x-ray, and that she entered the x-ray order into the radiology provider’s computer portal that same day. She stated the x-ray was not completed before the end of her shift and she was unaware it had not been done. The medical record contained no evidence that nursing staff followed up on the x-ray to determine if or when it was conducted or to obtain and report results to the physician. The DON stated that non-STAT x-rays may take a few days to be completed and reported that the radiology provider later indicated they had cancelled the x-ray because they did not have a credentialed radiologist to read the results, and that the provider did not inform facility staff of this cancellation. The DON stated it was her expectation that x-rays be obtained as ordered by the physician.
Inaccurate Wound Documentation and Incomplete ADL Charting
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a dependent resident with multiple pressure injuries. The facility’s charting and documentation policy required that services provided, progress toward care plan goals, and any changes in a resident’s condition be documented in the medical record, and that objective observations and treatments be recorded. The resident, admitted with multiple diagnoses including dementia, depression, muscle wasting, anxiety, and dysphagia, had a care plan and MDS indicating dependence on staff for most ADLs, including transfers, bathing, dressing, and personal hygiene. Despite this, nursing documentation in progress notes and at least one weekly skin evaluation repeatedly indicated that the resident’s skin was intact and that there were no pressure injuries over multiple dates in October, November, and December. A weekly skin evaluation on 11/14 also documented clean, intact skin. These entries conflicted with the resident’s pressure ulcer evaluations, which consistently documented a Stage 3 pressure injury to the sacrum on multiple dates, as well as additional Stage 2 and Stage 3 pressure injuries on the right sacrum, left sacrum, and left buttock. During interviews, the SDC and DON acknowledged ongoing issues with nurses documenting skin as intact when residents had open areas or pressure injuries, and a nurse who authored many of the notes admitted she had inaccurately documented the resident’s skin as intact and without pressure injuries. The facility also failed to ensure complete CNA documentation of ADLs for this resident. Review of CNA ADL flow sheets for October and November showed multiple days and shifts where all ADL care areas were left blank, including several day, evening, and night shifts each month. CNAs reported that ADL documentation is done in Point of Care in the EMR and must be completed by the end of each shift, and the DON stated that CNA documentation should not be incomplete and that all care provided should be documented by the end of every shift. Nonetheless, the records showed repeated omissions, resulting in incomplete daily documentation of the resident’s ADL care.
Documentation Deficiencies in Medication and Treatment Administration
Penalty
Summary
The facility failed to maintain accurate documentation of medication and treatment administration for four residents, leading to deficiencies in the Medication Administration Records (MAR) and Treatment Administration Records (TAR). For Resident #37, the MAR from November 2024 through January 2025 showed multiple instances where medications were not signed off as administered, despite physician orders. This included medications for conditions such as hypertension, diabetes, and depression. Similarly, Resident #50's MAR for December 2024 and January 2025 also had numerous unsigned entries for medications prescribed for dementia, diabetes, and depression, among other conditions. Resident #32, who has a suprapubic catheter due to traumatic spinal cord dysfunction, had missing documentation in the TAR for catheter care and cleaning from November 2024 through January 2025. The facility's failure to document these treatments as ordered by the physician indicates a lack of adherence to the facility's policy on charting and documentation. Additionally, Resident #23's MAR from November 2024 through January 2025 showed numerous unsigned entries for medications prescribed for diabetes and other conditions, further highlighting the facility's documentation issues. Interviews with nursing staff and the Director of Nursing (DON) revealed a lack of awareness and understanding of the documentation requirements. Nurse #3 was unaware of the documentation issues and mentioned that internet outages were not communicated effectively, leading to gaps in documentation. The DON acknowledged the problem but could not determine the cause, whether it was due to internet issues or residents being out of the facility. The expectation was for nurses to document medication and treatment administration before the end of their shifts, but this was not consistently followed, resulting in significant documentation deficiencies.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies in the care of three residents. For one resident, staff did not adhere to Contact Precautions, as evidenced by a nurse entering the resident's room without personal protective equipment (PPE) and failing to perform hand hygiene before and after administering medications and checking the resident's blood pressure. The nurse also did not sanitize the blood pressure cuff before using it on another resident. Additionally, a certified nursing assistant and a housekeeper entered the resident's room without PPE and did not perform hand hygiene, further compromising infection control measures. Another resident was under Enhanced Barrier Precautions (EBP) due to a surgical wound, yet the same nurse failed to perform hand hygiene and did not wear PPE when administering medications and checking the resident's blood pressure. The nurse also did not clean the blood pressure cuff between uses on different residents. This lack of adherence to EBP and hand hygiene protocols increased the risk of transmission of multidrug-resistant organisms (MDROs) among residents. A third resident, who had a gastrostomy tube, was observed with a piston syringe lying uncovered and undated on the bedside table, exposing it to potential environmental contaminants. The facility's policy required that such equipment be stored in a sanitary manner with a protective barrier and labeled with the resident's name and date. The nurse responsible for this resident acknowledged the lack of proper storage and labeling, indicating a failure to follow infection control guidelines for maintaining gastrostomy tube equipment.
Improper Disposal of Cigarette Butts in Smoking Area
Penalty
Summary
The facility failed to maintain a safe and clean environment in the designated smoking area by not properly disposing of cigarette butts in designated safe ashtrays. Observations revealed hundreds of cigarette butts scattered along the border of the smoking area, in bushes, and in planters by the door to the facility. Additionally, white glass bowls stained with a black substance and ashes were found in the bushes, and plastic outdoor self-extinguishing ashtrays were improperly maintained, with one having its neck disconnected from the bucket, leaving cigarette butts exposed. Cigarette butts were also found in trash cans lined with plastic bags containing empty cigarette boxes. Interviews with residents and staff highlighted issues contributing to the deficiency. A resident mentioned that the ashtrays often blew over in the wind, scattering cigarette butts. The Maintenance Director (MD) stated that he cleans the smoking area twice a week, but residents often do not dispose of cigarettes in the ashtrays despite being instructed to do so. The MD also noted that the outdoor ashtray was missing a screw, causing the top to come off, and he had removed all open ashtrays from the tables. The Administrator was unaware of the cigarette litter and the missing screw, despite a staff member being assigned to supervise all smoking sessions.
Failure to Develop Comprehensive Diabetic Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident with Diabetes Mellitus, resulting in a deficiency. The resident, admitted in October 2024, had diagnoses including Diabetes Mellitus with complications and diabetic neuropathy. Despite these conditions, the facility did not create a comprehensive care plan addressing the resident's diabetic management. The Minimum Data Set (MDS) assessment indicated the resident had diabetes and recent falls, but it did not include a Brief Interview for Mental Status (BIMS) to assess cognitive status. A later BIMS assessment revealed severe cognitive impairment, yet the care plan still lacked diabetic management. The hospital discharge summary noted the resident had experienced hypoglycemia due to poor intake, and their diabetic medication regimen was adjusted before discharge to the facility. Physician's orders included medications to manage blood sugar levels, but the comprehensive care plan did not reflect these needs. Interviews with facility staff, including a nurse and the Director of Nurses (DON), confirmed that a care plan for diabetes should have been in place, including monitoring blood sugars and having a diabetic order set. The absence of such a care plan and monitoring orders constituted a failure to meet the resident's needs.
Failure to Implement Physician Orders for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, resulting in deficiencies in care. For Resident #54, the facility did not implement the eye doctor's recommendation for eye drops. Despite the resident being cognitively intact and aware of the recommendation, the eye drops were not ordered or administered. Interviews revealed that the Director of Nursing expected new orders from a consultant physician to be communicated and implemented, but this process was not followed, and there was no policy in place for consultant physician appointments. For Resident #23, the facility did not enter or implement physician-recommended treatments into the electronic medical record. The resident, who had severe cognitive impairment, was admitted with diabetes and a history of falls. The physician's progress notes included orders for glucose monitoring, lab work, and a chest x-ray, but these were not carried out. Interviews indicated that the physician's notes were uploaded into the electronic medical record, but nurses did not routinely read them, and there was no unit manager to oversee this process. The physician expected the orders to be entered and implemented, but this did not occur. The lack of communication and follow-through on physician orders for both residents highlights a systemic issue in the facility's process for managing and implementing medical recommendations. The absence of a policy for consultant physician appointments and the failure to ensure that physician orders are read and acted upon contributed to the deficiencies observed in the care of these residents.
Failure to Provide Necessary Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide necessary adaptive equipment for a resident with hemiplegia following a stroke, specifically an ankle foot orthosis (AFO) brace and a left arm sling, which were essential for the resident's mobility and shoulder support. The resident, who had moderate cognitive impairment and a history of falls, was observed multiple times without the AFO brace and sling, despite physician orders indicating their necessity. The resident expressed discomfort with the AFOs provided, and the facility staff acknowledged the need for a custom AFO but did not follow through with obtaining one. Interviews with the rehabilitation staff and the Director of Nurses revealed a lack of communication and follow-up regarding the resident's need for a custom AFO. The rehabilitation staff trialed various AFOs, but they were uncomfortable for the resident, and the custom AFO was never arranged. Additionally, the resident's treatment administration record inaccurately indicated that the AFO was applied daily, despite its absence. The resident also reported that the sling was not regularly applied, and the AFO was removed by therapy staff due to discomfort, highlighting a failure in ensuring the resident's adaptive equipment needs were met.
Inadequate Enteral Feeding Management for Resident with G-tube
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Gastrostomy tube (G-tube), specifically in the administration of enteral feeding. The resident, who was admitted with diagnoses including dysphagia and intracranial hemorrhage, was observed to have discrepancies in the labeling and administration of their enteral nutrition. The feeding pump was set at 45 ml/hr with a flush of 150 ml every 6 hours, but the formula labels were inconsistent and sometimes incorrect, with one instance showing a different resident's name and room number. The facility's policy required that enteral formulas be labeled with specific information, including the resident's identifiers, formula name, date, and time of preparation, and administration details. However, observations revealed that the labels on the formula and water flush bags were incomplete or incorrect, leading to the administration of the wrong formula, Osmolite 1.5, instead of the prescribed Jevity 1.5. Additionally, the water flush bag was not changed as required, and the tubing set was not documented as changed every 24 hours, as per the physician's orders. Interviews with nursing staff revealed confusion and errors in following the physician's orders and facility policies. Nurse #4 admitted to changing the formula upon noticing the error but did not change the water flush bag or tubing. Nurse #2 acknowledged the labeling errors and confusion between different residents' formulas. The Director of Nursing confirmed that the physician's orders were not followed and that the labeling should have been completed accurately to prevent such errors.
Unsecured Medications Found in Residents' Rooms
Penalty
Summary
The facility failed to ensure that medications were stored securely in accordance with professional principles for two residents. Resident #31, who was cognitively intact and admitted with end-stage renal disease, had a bottle of Tylenol left unsecured in their room. The resident admitted to having a friend bring the medication into the facility, unaware that it was against policy to have unsecured medications in their room. There was no documentation of a Self-Administration of Medications Assessment for Resident #31, and Nurse #1 confirmed that the resident was not authorized to self-administer medications. Resident #67, who had moderate cognitive impairment and was admitted with glaucoma, had unsecured bottles of Timolol and Latanoprost eye drops in their room. These medications were found in a clear plastic bag on top of the resident's bureau. Nurse #1, who administered the eye drops daily, was unaware of their presence in the room and suggested they might have come from the hospital. The Director of Nursing confirmed that medications should not be kept in residents' rooms unless they are locked and secure, and a proper assessment and physician's order are in place for self-administration.
Failure to Conduct NAR Check Before Employment
Penalty
Summary
The Facility failed to adhere to its Abuse Policy by not conducting a Massachusetts Nurse Aide Registry (NAR) check for a nurse prior to her employment. The Facility's policy, revised in February 2024, mandates that an NAR check is performed before hiring any employee. However, upon reviewing the employee file of Nurse #1, it was found that her employment began on March 4, 2024, without any documentation of an NAR check being conducted beforehand. During an interview, the Administrator confirmed that all employees are required to have an NAR check before starting employment, but the Facility could not provide evidence that this was done for Nurse #1.
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What surveyors actually found near you
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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 Taunton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marian Manor Of Taunton | 0.9 mi | ★★★★★ | 1 | 0 |
| Regalcare At Taunton | 1.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Raynham | 1.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of West Bridgewater | 7.4 mi | ★★★★★ | 0 | 0 |
| Oakhill Healthcare | 8.2 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.