Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Newton Healthcare during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
Pressure ulcer care and skin monitoring were not consistently provided for multiple residents. A resident with a stage 4 heel ulcer was left without a functioning air mattress after a room move, another resident with a stage 3 ischial ulcer received wound care that did not match the wound physician’s recommended silver-containing treatment, a third resident’s air mattress was found set far above the ordered setting, and a high-risk resident did not have weekly skin checks completed on time. Staff interviews confirmed the missed or incorrect care and documentation.
Failure to Provide and Document Dental Services: The facility did not ensure dental care was carried out for multiple residents with dental needs and provider orders. One resident waited about a year for dental consent and was never seen by a dentist, while others had tooth pain, broken teeth, or requests for dentures with no documented dental follow-through, no completed consent or service records, and no evidence of dental visits despite physician orders and resident requests.
Failure to Ensure Timely Influenza Vaccination: The facility failed to maintain an effective immunization program for 11 of 27 residents. Records showed no documentation that these residents were offered or given the flu vaccine, despite policy requiring annual offering of the vaccine to eligible residents and CDC guidance that vaccination should occur when available and ideally in early fall. The DON stated the facility had vaccine available, obtained orders and consent before administration, and vaccinated residents with consent, but acknowledged some residents still had not received the flu vaccine despite having orders and consent.
Staff Cellphone Use in Resident Dining Room: A CNA was observed in the resident dining room with her personal cellphone while residents were present, including one instance where she was texting in view of residents and another where she was standing with her phone in hand and not interacting with residents. The UM, Corporate Nurse, and DON stated residents are expected to have a dignified existence and staff should not be on their phones in front of residents.
A resident with traumatic brain injury, abnormal posture, and a history of falls had an MDS that coded one fall with minor injury despite record review showing a fall with a subacute L1 compression fracture. Nursing notes, an incident report, and hospital records documented the fall and fracture, and the MDS Nurse stated the fracture should have been coded as a major injury per the RAI manual.
Failure to provide timely ADL assistance affected three residents. One cognitively intact resident who was dependent for toileting and incontinent of bowel and bladder remained wet or soiled in a wheelchair for hours despite a care plan calling for checks and changes every 2 to 3 hours. A second resident with severe dementia and bowel/bladder incontinence was observed sitting in the dining room for extended periods without staff checking or changing the brief, which was later found soiled and swollen with urine. A third resident who required supervision with eating was repeatedly observed eating meals in the room without staff supervision, despite the care plan and Kardex directing supervised meals.
Failure to provide an ongoing activities program for a resident with severe cognitive impairment and a language barrier. The resident’s care plan and recreation assessments identified interests such as music, TV, coloring, nail painting, and one-on-one interaction, but staff repeatedly left the resident seated alone in the dining room without engaging him/her or offering individualized activities. The facility also did not have a Resident Activities policy, and CNA documentation showed limited activity participation.
A resident with severe cognitive impairment, dementia, an abdominal wound, and a history of skin-picking had dark red scab-like areas and open areas on both feet that were observed by surveyors, but the nursing record did not document or monitor the findings. The resident’s care plan addressed picking at the abdominal wound, while the TAR showed heel-related preventive treatments were signed off as given, yet staff did not identify the foot injuries during routine contact. CNA staff said the resident picked at the feet and nurses knew about the areas, while the DON stated staff should be aware of new skin areas even when the resident has known behaviors.
Failure to Implement Ophthalmology Orders: A resident with cataract and glaucoma did not receive the ordered post-op eye drop taper after eye surgery, and Cosopt was not stopped as directed. The MAR showed prednisolone was discontinued early, while nursing and PA notes reflected the resident had dizziness and bradycardia while still on Cosopt. Staff interviews confirmed the ophthalmology recommendations were not fully reviewed or implemented.
A resident with adult failure to thrive, dementia, and DM had an 8.03% weight loss identified by the RD, who questioned the accuracy of the weight and recommended a reweigh. The record did not show a confirmatory re-weigh until 20 days later, and the RD, CNA, UM, Corporate Nurse, and DON all stated the reweigh should have been done much sooner.
Missing Physician Order for Oxygen Therapy: A resident with anoxic brain injury, trach status, and severe cognitive impairment was observed receiving oxygen via trach mask at 5 LPM on multiple occasions. The care plan and RT note referenced oxygen therapy, but the chart lacked a physician order for oxygen use, and an RN and the DON acknowledged that oxygen administration requires an order.
A resident with a suprapubic catheter and enhanced barrier precautions was observed receiving direct care from an RN without PPE. The RN was seen near the catheter drainage bag, taking vital signs with a multi-use BP cuff, and assisting the resident with toileting while not wearing the required gown and gloves. The RN, UM, and DON all acknowledged that PPE should have been worn.
Failure to Post Daily Nursing Staffing Information: Surveyors observed that the daily staffing posting was outdated and no current staffing sheets were posted. Interviews showed the Scheduler did not print weekend staffing sheets because she did not know the census, and the weekend managers on duty were not aware they were responsible for posting the staffing information.
Two residents dependent on staff for feeding were not provided with a dignified dining experience. One resident with Alzheimer's was left without assistance, eating with their hands, and crying without being consoled. Another resident with dementia and dysphagia waited long periods for help and was left with covered trays. Staff referred to residents as 'feeders' and a CNA sat on a chair arm while assisting a resident, contributing to the undignified experience.
The facility failed to meet professional standards for three residents, including inadequate follow-up on elevated PSA levels for a resident, incorrect medication administration via g-tube for another, and unclear g-tube flush orders for a third. These deficiencies highlight issues in communication and adherence to physician orders.
The facility failed to provide necessary assistance with ADLs for three residents, leading to deficiencies in care. A resident with Alzheimer's was left without help during meals, unable to reach or consume food independently. Another resident with dysphagia and contractures was not properly assisted with meals, despite visible struggles. A comatose resident did not receive routine grooming care, as staff neglected to perform necessary shaving. These failures highlight significant lapses in providing essential care and support.
A facility failed to provide routine laboratory services according to a physician's orders for a resident with multiple diagnoses, including dementia and diabetes. The resident's lab tests, such as CBC and CMP, were not consistently obtained as required. Interviews revealed that nurses were responsible for processing lab requisitions, but the Director of Clinical Operations could not provide evidence of consistent lab work.
The facility failed to follow safe food practices in its kitchen, leading to potential contamination of food items. Observations revealed unlabeled and undated food, spoiled produce, and opened containers without proper dating. Interviews with the Food Service Director and Corporate Food Service Director highlighted a lack of adherence to labeling and discarding guidelines, indicating a systemic failure to maintain food safety standards.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a PICC line and another with an external dialysis catheter, due to staff not following proper infection control protocols. Additionally, during meal service, staff placed soiled dishware back into carts with meals awaiting delivery, violating facility policy and posing an infection control risk.
A facility failed to identify and minimize areas of possible entrapment in resident beds, particularly for a resident with a traumatic brain injury and history of falling. The facility did not conduct routine inspections on the resident's bed frame and mattress, and significant gaps between bed rails and the headboard and footboard were not assessed. The Maintenance Director assumed large gaps would pass entrapment assessments without proper evaluation, and the facility lacked protocols for periodic bed assessments.
A resident's guardian expressed concerns about the resident's care, including unclean bedding and poor hygiene, which were not addressed by the facility. The Social Worker failed to file a grievance or inform nursing staff, contrary to the facility's policy. Observations confirmed the resident's unkempt condition, and the grievance was only documented after the Ombudsman intervened.
A facility failed to assess and document the use of an abdominal binder as a restraint for a resident with a traumatic brain injury and feeding tube. The resident was unable to self-release the binder, which was used to prevent accidental removal of the PEG tube. The facility's policy requires a pre-restraining evaluation and consent, but the resident's plan of care lacked documentation and consent for the binder's use.
A facility failed to accurately code the MDS assessment for a resident with severe COPD, leading to a deficiency. The resident, who was cognitively intact and required assistance with daily activities, was documented to use oxygen at 2 LPM due to severe COPD. However, the MDS assessment incorrectly indicated no need for oxygen. The Director of Clinical Operations confirmed the oversight in coding.
The facility failed to implement comprehensive care plans for residents, including ensuring bed safety measures, addressing mental health needs, and managing psychotropic medication use. Observations showed non-compliance with physician orders and care plans, and staff interviews revealed a lack of awareness and communication regarding residents' care needs.
The facility failed to update care plans for two residents. One resident's care plan did not reflect the current oxygen flow rate for a tracheostomy, while another resident's smoking safety plan inaccurately required a smoking apron that was never used. Both care plans were not revised to match current assessments and practices, as required by facility policy.
A resident with absolute glaucoma and an artificial left eye experienced a deficiency in vision services when the facility failed to repair their broken eyeglasses. Despite the resident's severely impaired cognition and the risk posed by the broken glasses, no referral was made for repair, and staff were unaware of any actions taken. The facility did not follow the communication care plan to ensure assistive devices were in place.
A facility failed to implement physician-ordered interventions for a resident with pressure ulcers, leading to a deficiency. The resident, with a history of diabetes and depression, had multiple pressure ulcers. Despite orders for Prevalon boots and heel elevation, these were not consistently provided. Observations showed the resident's heel was not elevated, and interviews confirmed the lack of boots, highlighting a lapse in following the care plan.
A facility failed to provide appropriate ROM care for a resident by not obtaining physician's orders for hand splints as recommended by an OT. The resident, with anoxic brain damage and chronic respiratory failure, was observed wearing splints without a documented schedule. Staff interviews revealed uncertainty about the splint schedule, and the Director of Clinical Operations confirmed the absence of necessary orders in the health record.
A facility failed to monitor and document a resident's weight changes, leading to unaddressed significant fluctuations. The resident, with end-stage renal disease, had only one weight recorded despite policy requiring weekly checks. Dialysis records showed significant weight changes, but these were not reviewed or documented. Staff interviews revealed a lack of communication and documentation regarding the resident's weight management.
A resident with COPD received improper respiratory care as the facility failed to adhere to physician orders for oxygen flow rate and nebulizer tubing changes. The resident was observed receiving oxygen at a higher rate than prescribed, and nebulizer tubing was not changed weekly as ordered. Staff interviews confirmed these discrepancies.
The facility failed to create trauma-informed care plans for three residents with histories of trauma, including sexual abuse and PTSD. One resident lacked a care plan despite a new diagnosis of Adult Sexual Abuse, while another with a history of physical and sexual abuse also had no trauma assessment or care plan. A third resident with PTSD did not have a care plan addressing specific triggers and interventions. Staff interviews confirmed the expectation for such plans.
A resident with a traumatic brain injury and history of falls had side rails improperly implemented, contrary to their care plan. The facility's documentation was incomplete, lacking a proper consent form and physician's order specifying the type and size of the side rails. Staff interviews revealed inconsistencies in understanding the use of side rails, and the facility did not have a policy in place for side rail use.
A facility failed to maintain a medication error rate below 5%, with one nurse making 10 errors out of 43 opportunities, resulting in a 20.93% error rate. Two residents were affected, with several medications either administered at incorrect times or not given at all. The Director of Clinical Operations confirmed that medications should be administered as ordered.
The facility failed to ensure proper storage and security of drugs and biologicals. A nurse gave medication cart keys, including narcotic keys, to an unassigned staff nurse, allowing access to the cart. Additionally, surveyors found an unlocked medication cart on two occasions while the assigned nurse was attending to residents elsewhere. The Director of Clinical Operations confirmed the expectation for nurses to maintain control of their cart keys and ensure carts are locked when unattended.
A facility failed to provide necessary dental services for a resident with kidney and heart disease, who experienced mouth discomfort and gum inflammation. Despite a physician's order for dental consults and a prescription for Amoxicillin, the resident was not seen by a dentist as expected. The Director of Clinical Operations confirmed that a dental consult should have been obtained.
The facility failed to maintain accurate medical records for two residents. One resident's TAR inaccurately documented bed positioning and fall mat placement, while another resident's MAR failed to record medication administration. Observations and interviews revealed discrepancies between documented care and actual conditions, with staff unaware of documentation expectations.
The facility did not post daily nurse staffing information as required, with outdated data observed on multiple occasions. The Scheduling Coordinator and Administrator acknowledged the lapse in updating the staffing information.
A facility failed to follow physician's orders for a resident with severe malnutrition, resulting in pressure injuries on the resident's heels. The resident was observed without prescribed heel booties and with an incorrectly set air mattress, leading to the development of a reddened area and a deep tissue pressure injury. Staff were unaware of the resident's heel issues and did not follow the correct procedures for pressure ulcer prevention.
The facility failed to provide an ongoing program of activities to meet the residents' needs, as multiple residents and staff reported the absence of activities. Observations confirmed that scheduled activities were not held, and the facility lacked an Activity Director and a specific QAPI plan to ensure the continuation of the activity program.
The facility failed to honor the smoking preferences of two residents during a Covid outbreak. Both residents, who were cognitively intact and had care plans indicating supervised smoking, were not provided with alternative measures to smoke. Staff interviews revealed a lack of awareness and a clear plan for managing smokers during the outbreak, leading to frustration and unmet needs for the residents.
The facility failed to develop and implement care plans for three residents, leading to deficiencies in their care. One resident did not receive required meal supervision, another did not have a recommended scoop mattress for fall prevention, and a third did not have a care plan for suicidal ideation despite documented mental health concerns.
The facility failed to ensure proper care for four residents, including inadequate monitoring of a PICC line, not following a physician's recommendation for a hand surgeon consult, not reviewing hospice medication recommendations, and administering an incorrect supplement to a diabetic resident.
The facility failed to assess and treat a resident after a decline in functional status, did not provide appropriate communication services for a resident with a language barrier, and did not provide adequate assistance with meals for two residents. These deficiencies led to residents experiencing agitation, frustration, and potential risks due to lack of proper care and supervision.
The facility failed to change oxygen tubing according to physician's orders for three residents and did not change an oxygen concentrator filter for one resident. Observations revealed outdated tubing and uncleaned filters, with staff unsure of responsibilities and frequency for these tasks. The Director of Nursing confirmed the need to follow physician's orders for maintenance.
The facility failed to ensure that annual competencies were completed and documented for six CNAs and six licensed nurses. The Administrator and ADON acknowledged the deficiency, with the ADON noting that efforts were underway to complete the required competencies.
The facility failed to complete annual CNA performance reviews for six sampled CNAs. During a review, it was noted that none of the CNAs received their annual reviews. The DON and Administrator indicated that Corporate is responsible for these reviews, but there was uncertainty about who was completing them.
A resident did not receive their physician-ordered Trazodone for anxiety and depression because the nurse failed to check the emergency medication supply, despite the medication being available. The DON confirmed the medication was in the emergency kit and had been recently delivered.
The facility failed to maintain a medication error rate below 5%, with three nurses making four errors in 38 opportunities, resulting in a 10.53% error rate. Errors included incorrect dosages and administering the wrong type of medication, impacting three residents.
The facility failed to ensure a resident was free from significant medication errors by not adhering to physician orders for administering Midodrine HCL. The resident received the medication despite blood pressure readings being outside the specified parameters, leading to a significant medication error.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Pressure ulcer care and skin monitoring not consistently provided
Penalty
Summary
The facility failed to provide consistent pressure ulcer care and skin monitoring for four residents who were identified as being at risk for skin breakdown or who already had pressure ulcers. The report states that Resident #5 had a stage 4 pressure ulcer on the left medial heel and was ordered to use an air mattress set to #2, but the mattress was not moved with the resident when the room was changed, and surveyors later observed the mattress unplugged, disconnected, and not inflated. The resident was also observed on a standard mattress with heels directly on the mattress while in the temporary room. Resident #98 had a stage 3 pressure ulcer of the left ischium and was ordered to receive wound care with hydrogel and xeroform gauze, while the wound physician’s recommendations indicated hydrogel with silver. Surveyors observed the wound treatment being performed using a later transcribed order for silvasorb gel and xeroform gauze after the corporate nurse changed the order because the facility had run out of hydrogel. Review of the treatment record showed staff had been applying hydrogel rather than hydrogel with silver, and the corporate nurse and DON acknowledged that the resident should have been receiving hydrogel with silver as recommended by the wound physician. Resident #62 had a stage 3 pressure ulcer and was ordered to have an air mattress set to 100 pounds, but surveyors repeatedly observed the mattress pump set to 250 pounds. Staff stated the setting was too firm and should have matched the resident’s weight or the physician’s order. Resident #9 was assessed as high risk for pressure injuries, but the record did not show weekly skin evaluations completed weekly and timely; the physician’s orders did not include a weekly skin evaluation order, and the documented weekly skin evaluations showed a gap, with the last documented evaluation recorded on 12/1/25. Staff interviews confirmed that weekly skin checks were expected and that the resident’s weekly skin evaluation had been missed and was overdue.
Failure to Provide and Document Dental Services
Penalty
Summary
The facility failed to provide routine dental services and follow through on dental-related physician orders for four residents. The report states that the facility had a policy for routine dental services through a contracted dentist and that nursing or social services staff were to assist with appointments and record services in the medical record, but the records reviewed did not show that this occurred for the residents identified in the sample. Resident #51 was admitted in November 2024 with adjustment disorder and anxiety disorder and had intact cognition on MDS review. The resident was observed to have no bottom teeth and most teeth missing, stated that he/she had not seen a dentist since admission, and said he/she wanted to see a dentist and learn about dentures. Although a dental consult order was present from admission and the care plan referenced referral to a dentist as needed, the consent for dental services was not signed until one year after admission. The record did not show any dental visit, and the resident was not listed on the September 2025 dental visitation log. Resident #81 was admitted in May 2025 with diagnoses including adult failure to thrive, major depression, and cognitive impairment, and was cognitively intact on MDS review. The resident reported a missing tooth and tooth pain and requested to see the dentist. The record contained physician orders for dental evaluation and a signed request for service, but the resident was not included on the facility dental visit list and the record did not show any dental visits since admission. Resident #73, admitted in September 2024 and cognitively intact, reported having seen the dentist and waiting for dentures. A dental exam documented that the resident had no teeth and wanted full upper and lower dentures, with staff asked to have the responsible party sign a consent for denture form; however, the medical record did not contain that consent form. Resident #72, admitted in October 2022 and cognitively intact, reported broken teeth and difficulty managing food. A physician ordered dental follow-up for a broken tooth affecting swallowing, but the record showed a blank request for service more than three years after admission and no documentation of oral assessment, dental contact, consent for dental services, or dental visits.
Failure to Ensure Timely Influenza Vaccination
Penalty
Summary
The facility failed to have an effective immunization program in place for 11 of 27 residents, with the deficiency centered on influenza vaccination. Review of the facility policy titled Influenza Vaccine showed that residents without medical contraindications were to be offered the influenza vaccine annually, that residents admitted between October 1 and March 31 were to be offered the vaccine, and that education about the benefits and potential side effects was to be provided before vaccination and documented in the medical record. CDC guidance reviewed by surveyors stated that everyone 6 months and older should get a flu vaccine every season and that vaccination is ideally recommended in September or October, before the season peaks. Review of 27 resident medical records showed that 11 residents did not have documentation indicating they were offered or administered the influenza vaccine. During interview, the DON stated that the facility’s influenza program included immunizing everyone with consent, that an order had to be obtained and transcribed to the MAR, and that the vaccine was recorded in the electronic record after administration. He stated that the facility vaccinated the first wave of residents in October for those with consent and who wanted the vaccine, that new admissions were offered the vaccine, and that the vaccine was available at that time. He also stated there had been resistance from residents and delays in getting consents returned from legal representatives, and acknowledged there was no real excuse for why some residents had not received the influenza vaccine despite having orders and consent since October.
Staff Cellphone Use in Resident Dining Room
Penalty
Summary
The facility failed to ensure that residents on the third-floor unit were provided with a dignified existence when staff members used personal cellphones in the resident dining room while residents were present. On 12/15/25 at 10:48 A.M., multiple residents were observed sitting at tables in the dining room while a CNA stood leaning against the counter with her cellphone in her hand and not interacting with any residents. On 12/16/25 at 10:30 A.M., multiple residents were again observed in the dining room while a CNA sat in a chair documenting care on a tablet and texting on her personal cell phone in view of residents. During interviews on 12/18/25, Unit Manager #2, Corporate Nurse #2, and the DON stated that all residents are expected to have a dignified existence and that staff should not be on their phones in front of residents, including in the dining room.
MDS Assessment Failed to Code Fall With Major Injury
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident by not coding a fall with major injury. Resident #2 was admitted with diagnoses including traumatic brain injury, abnormal posture, and a history of falling, and the 10/10/25 MDS showed severe cognitive impairment with a BIMS score of 3 out of 15. That assessment coded the resident as having one fall with minor injury. Record review showed that on 7/30/25 the resident was found on the floor with a knot to the left forehead, and nursing documentation noted the resident had fallen in the room and was later sent back to the facility after a head strike. The hospital records and discharge summary documented a subacute compression fracture of the L1 vertebra, and the RAI manual states that a major injury includes bone fractures. During interview, the MDS Nurse stated she codes falls based on the RAI manual and should have coded the L1 fracture as a fall with major injury, but did not. The Director of Clinical Operations stated that falls should be coded according to the RAI manual.
Failure to Provide Timely Incontinence Care and Meal Supervision
Penalty
Summary
The facility failed to provide timely ADL assistance for dependent residents, including incontinent care and meal supervision, as reflected in observations, record review, and staff and resident interviews. The facility policy stated that residents unable to perform ADLs independently would receive appropriate support and assistance with elimination and dining. Three residents were identified in the deficiency: one resident who was cognitively intact but dependent on staff for toileting and incontinent of bowel and bladder; one resident with severe cognitive impairment who was dependent for toileting and incontinent of bowel and bladder; and one resident with intact cognition who required supervision or touching assistance with eating. Resident #57 was admitted with diagnoses including muscle weakness, lupus, cervical spondylopathy, and anxiety. The MDS showed the resident was cognitively intact, dependent on staff for daily care activities including toileting, incontinent of bladder and bowel, and at risk for pressure injuries. The resident told the surveyor on multiple occasions that he/she had been out of bed for hours, had not been changed, and was wet or soiled. Observations showed the resident remained in a wheelchair in the activity/dining room for extended periods, including through meals and later in the afternoon, while stating that no one had approached to change him/her. The record showed a care plan and Kardex directing staff to check and change the resident every 2 to 3 hours and as needed, and staff interviews confirmed that incontinent residents should be checked and changed every 2 to 3 hours. Staff also stated the resident was often wet and sometimes soiled and that the resident had not been changed while up in the wheelchair that day. Resident #88 was admitted with diagnoses including Alzheimer’s disease, dementia, chronic kidney disease stage 3b, anxiety disorder, and heart failure. The MDS showed severe cognitive impairment and substantial to maximal assistance needs for toileting hygiene and toilet transfer, with staff assistance needed for walking. The care plan and Kardex identified the resident as incontinent of bowel and bladder and directed staff to provide incontinent care every occurrence, with toileting assistance and supervision. Surveyor observations over two days showed the resident sitting in the dining room corner for hours without staff being observed checking or offering to change him/her. When staff finally assisted, the brief was described as soiled and swollen with bright yellow urine. Staff interviews confirmed that incontinent residents should be checked every 2 to 3 hours and that this resident should have been checked sooner. Resident #13 was admitted with diagnoses including schizophrenia, dementia, and muscle weakness. The MDS indicated intact cognition and a need for supervision or touching assistance with eating. The Kardex and ADL care plan directed supervision with set-up help for eating and stated that the resident preferred to eat in his/her room and ate meals supervised in the main dining room as tolerated. Surveyor observations on multiple occasions showed the resident eating meals in his/her room without staff present in the room or supervising from the hallway. Staff interviews reflected that some staff believed the resident was independent with meals and did not need supervision, while management stated staff should follow the care plan and Kardex for the resident’s ADL needs.
Failure to Provide an Ongoing Activities Program for a Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide and implement an ongoing activities program for one resident, Resident #88, to meet his/her needs for engagement in meaningful activities. Resident #88 was admitted in April 2020 with diagnoses including Alzheimer's disease, dementia, chronic kidney disease stage 3b, anxiety disorder, and heart failure. The most recent MDS showed severe cognitive impairment, substantial/maximal assistance needed for toileting hygiene and toilet transfer, and staff assistance with walking. The annual MDS and care plan identified interests such as reading, music, group activities, favorite activities, time outdoors, TV, art projects, one-to-one attention, coloring, and nail painting, and noted a language barrier with Cantonese as the primary language. The facility did not have a Resident Activities policy when requested by the surveyor. The CNA documentation for December 2025 showed activity participation documented only on 12/2/25 and 12/4/25 through 12/17/25. The recreation assessments completed by the Activities Director noted that the resident participated in music programs, enjoyed singing, liked family visits, spent time with other residents in the activities room, watched TV, colored, and preferred one-on-one visits, but also stated the resident did not like larger groups due to the language barrier. Despite these documented preferences, the surveyor observed the resident repeatedly seated in the corner of the third-floor dining room, out of direct sight of staff, with his/her head resting face down on a bedside table and no activities in front of him/her. During multiple observations on 12/15/25, 12/16/25, and 12/17/25, staff were present in the dining room but did not engage the resident or offer activities. On one observation, three CNAs were in the dining room, with one documenting on an iPad and another on a personal cell phone, while the resident remained unattended in the corner. When the Activities Director came to invite residents to live music, she did not attempt to speak to the resident. The resident was also observed with an English-language activity calendar and the TV playing an English show, while no individualized activities such as art projects, music, coloring, or nail painting were offered during the survey observations. Interviews confirmed that staff should have been offering activities and engaging the resident, and the Activities Director stated she expected staff to pass out activities to residents not involved in group activities.
Failure to Identify and Document Foot Skin Injuries
Penalty
Summary
The facility failed to identify skin injuries on the soles of Resident #87’s feet and did not document or monitor those areas in the clinical record. Resident #87 was admitted in March 2023 and had diagnoses including iron deficiency anemia, an open abdominal wound, malignant neoplasm of the liver and bile duct, impulsiveness, adult failure to thrive, and dementia. The most recent MDS indicated severe cognitive impairment, partial/moderate assistance needed for lower body dressing including footwear, and behaviors including rejection of care. The resident’s care plan addressed behavior and picking at the abdominal wound, but did not include interventions related to picking or injuring the feet. During observations on 12/15/25, 12/16/25, and 12/17/25, surveyors saw dark red scab-like areas and open areas on the left great toe and sole of the left foot, along with dark red scab-like areas on the sole of the right foot. The resident was seen in bed with feet exposed, walking in croc-like shoes without socks, and later asked what was wrong with the feet. The weekly skin evaluations did not document these areas, and the progress notes from 12/1/25 through 12/16/25 contained no documentation about the foot findings. The last documented weekly skin evaluation before the resident refused one on 12/12/25 was dated 10/29/25. The physician’s orders included moisture barrier to heels and buttocks and skin prep to bilateral heels for prevention, and the TAR showed these treatments were signed off as given multiple times each day and each shift. Despite this, nursing staff did not identify or document the areas on the soles of the feet. Nurse #5 stated she was not aware of any other areas on the feet and had not received report of them, while CNA #1 stated the resident had behaviors of picking at the feet and that nurses knew about areas on the bottom of the feet. The DON stated nursing staff should be aware of new skin areas, even with known behaviors, to monitor and provide treatment as indicated.
Failure to Implement Postoperative Eye Drop Orders
Penalty
Summary
The facility failed to ensure that Resident #43 received proper treatment to maintain vision ability after eye surgery. Resident #43 was admitted with diagnoses including right eye cataract, glaucoma, and lack of coordination, and was cognitively intact with a BIMS score of 15 and adequate vision on the most recent MDS. The resident’s plan of care included arranging consultation with an eye care practitioner as needed. After a postoperative ophthalmology visit, paperwork dated 12/2/25 directed that Cosopt be stopped and that prednisolone eye drops be tapered from four times daily to three, then two, then one time daily over successive weeks, with follow-up scheduled for 12/23/25. The facility did not implement those ophthalmology recommendations. The MAR showed the prednisolone eye drops were discontinued after 12/5/25, despite the taper instructions, and Cosopt was not discontinued as directed. Nursing documentation noted the resident complained of dizziness with bradycardia, and the PA wanted ophthalmology notified about the low heart rate and dizziness while the resident was on Cosopt due to concern for beta-blocker effect. Staff interviews showed the nurse reviewed the returned paperwork and obtained the next appointment order, but did not notice the eye drop recommendations; the PA stated all ophthalmologist recommendations should be implemented by nursing, and the DON stated follow-up recommendations from the hospital should be reviewed by nursing and implemented.
Delayed Re-weigh After Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident by not obtaining a re-weigh in a reasonable amount of time after a significant weight loss was identified. The resident was admitted in July 2025 with diagnoses including adult failure to thrive, dementia, and type 2 diabetes mellitus, and the most recent MDS showed severe cognitive impairment with full dependence on staff for all activities of daily living. The facility policy required verification of weights when significant weight changes occurred, with suggested parameters including 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. The resident’s weight record showed 122 pounds on 10/7/25 and 112.2 pounds on 11/6/25, a loss of 9.8 pounds or 8.03%. The RD documented on 11/6/25 that the weight loss was questionable and recommended a reweigh to confirm, noting a diuretic. However, the medical record did not show a re-weigh until 11/26/25, 20 days later, and there was no physician order indicating the resident was to be weighed. During interviews, the RD, CNA, Unit Manager, Corporate Nurse, and DON all stated that a reweigh should have been obtained sooner, with the DON stating reweighs should occur within 24-48 hours of a significant weight change.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that respiratory care and services were provided consistent with professional standards of practice for one resident. Resident #56 was admitted with diagnoses including anoxic brain injury, tracheostomy status, and a sacral pressure ulcer, and the most recent MDS showed severe cognitive impairment with a BIMS score of 0 out of 15. The resident was dependent on staff for activities of daily living and received oxygen therapy and tracheostomy care. The care plan for altered respiratory status and tracheostomy indicated oxygen at 6 liters per minute via trach mask, and an RT note recommended humidified oxygen at 6 liters per minute via trach mask every shift. Survey observations on multiple occasions showed Resident #56 receiving oxygen at 5 liters per minute. During an interview, Nurse #3 stated that oxygen administration is based on physician orders and that the concentrator could not go above 5 LPM. Review of the physician orders on 12/17/25 did not include an order for oxygen administration. Nurse #1 stated that oxygen use requires a physician's order and confirmed there was no order, and the DON also stated that there should be a physician's order for oxygen therapy.
Failure to Use PPE During Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident in the sample. Resident #85 was admitted with diagnoses including diabetes, dementia, and urine retention, and the most recent MDS indicated moderate cognitive impairment with a BIMS score of 6 out of 15 and the need for an indwelling catheter. The resident’s care plan identified enhanced barrier precautions for a suprapubic catheter, and the physician’s order directed a suprapubic catheter with continuous drainage to a bag while in bed. The physician assistant note documented treatment for Proteus mirabilis UTI and urine studies that also grew vancomycin-resistant Enterococcus faecalis, with Macrobid ordered. During observation, Resident #85 was seen in bed with pants pulled down below the knees and a catheter leg bag with yellow urine. Nurse #2 was observed bent near the catheter drainage bag without PPE, then obtaining routine vital signs with a multi-use blood pressure cuff. When the resident requested to use the bathroom, Nurse #2 transferred the resident from bed, pulled up the pants, walked the resident to the bathroom, lowered the pants, and assisted the resident onto the toilet. During interview, Nurse #2 stated she should have worn PPE while providing care but did not. Unit Manager #1 stated she observed Nurse #2 providing care without PPE, and the DON also stated that Nurse #2 should have worn PPE while caring for the resident.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post nursing staff data daily at the start of each shift as required. On 12/15/25 at 6:42 A.M., surveyors observed that the daily staffing posting was still dated Friday 12/12/25 at 1:55 P.M., and there were no additional staffing sheets underneath it. This showed that the staffing information was not being consistently updated and posted as required. During interviews, the Scheduler said she was supposed to update and post the daily staffing sheets Monday through Friday, while the person in charge was responsible for printing the weekend staffing sheets. She stated she did not print them on Friday because she did not know the facility census, and she noticed on 12/15/25 that the staffing sheet was still dated 12/12/25. The Administrator said the plan was for the Scheduler to post staffing sheets during the week and for the manager on duty to post them on weekends, but he also said the manager on duty roles and responsibilities were a work in progress. The Food Service Director, who was the manager on duty on Saturday, said he was not aware he was supposed to hang up the daily staffing information, and the Housekeeping Supervisor, who was the manager on duty on Sunday, said she was also not aware she was supposed to hang the schedule for the weekend.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents who were dependent on staff for feeding. Resident #23, who has Alzheimer's dementia and anxiety disorder, was observed in several instances where staff did not provide the necessary assistance for feeding. On one occasion, the resident was left lying flat in bed with a breakfast tray out of reach. Later, the resident was seen eating with their hands and placing a cup of milk on their food without receiving assistance. Despite being visibly upset and crying, staff did not console or assist the resident promptly. Resident #50, diagnosed with dementia and dysphagia, also experienced a lack of timely assistance during meals. The resident was left with covered food trays and had to wait for extended periods before receiving help. On one occasion, a staff member was observed texting on their phone while feeding the resident. The resident's care plan indicated a need for partial to moderate assistance with eating, yet the staff failed to provide the necessary support promptly. Additionally, the facility staff referred to residents as 'feeders' rather than by their names, which is considered undignified. In one instance, a CNA was observed sitting on the arm of a chair while assisting a resident with eating, which was deemed inappropriate. These actions and inactions by the facility staff contributed to a failure in providing a dignified dining experience for the residents.
Deficiencies in Medication Administration and Follow-Up Care
Penalty
Summary
The facility failed to meet professional standards of practice for three residents, leading to deficiencies in care. For Resident #14, the facility did not follow up on an elevated PSA level, a potential indicator of cancer. Despite multiple elevated PSA test results, the facility did not schedule a timely urology consultation, and there was a lack of communication regarding the necessary follow-up, leaving the resident without appropriate medical evaluation and discussion of treatment options. Resident #35, who was admitted with anoxic brain damage and required a feeding tube, received medications via g-tube despite physician orders indicating oral administration. The nursing staff did not clarify the physician's orders, resulting in a discrepancy between the prescribed route of administration and the actual method used. This oversight was acknowledged by the Director of Clinical Operations, who confirmed that medications should be administered as ordered. For Resident #74, the facility failed to clarify conflicting physician orders regarding g-tube flushes. The resident's orders indicated different frequencies for water flushes, leading to confusion and incorrect administration. The nursing staff followed the unclear orders, administering flushes more frequently than intended. The Director of Clinical Operations recognized the need for clarification of the orders to ensure proper care.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents, leading to deficiencies in care. Resident #23, who has Alzheimer's dementia and anxiety disorder, was observed to be dependent on staff for eating and bed mobility. Despite this, staff failed to assist the resident with meals, leaving the resident unable to reach or consume food independently. Observations showed that staff placed meal trays out of reach and did not provide the necessary assistance, resulting in the resident attempting to eat with their hands and being left without help even when visibly struggling. Resident #5, diagnosed with dysphagia and contractures, also did not receive adequate assistance with meals. The resident, who requires supervision or touching assistance due to impaired upper extremities and difficulty feeding themselves, was left unsupervised with meal trays. Staff failed to position the resident properly for eating, and despite the resident's visible struggle with shaking hands and inability to self-feed, no assistance was provided. This lack of support was observed multiple times, with staff neglecting to offer the necessary help even when the resident requested assistance. Resident #7, who is comatose and dependent on staff for ADLs, was not provided with appropriate grooming care. The resident was observed with facial hair that should have been shaved during routine care, as indicated in the care plan. Interviews with staff revealed that grooming tasks such as shaving were not performed as required, with CNAs and nurses acknowledging the oversight. The failure to provide routine grooming care was evident in the resident's unshaven appearance over several days.
Failure to Provide Routine Laboratory Services as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were provided according to the physician's orders for a resident. The resident, who was admitted with diagnoses including dementia, tracheostomy, diabetes, and seizures, was comatose at the time of the deficiency. The physician's orders required routine laboratory tests, including CBC, CMP, LFT, magnesium, and phosphorus, to be conducted on specific days. However, a review of the resident's laboratory results indicated that these tests were not consistently obtained as ordered. Interviews with facility staff revealed that it was the nurses' responsibility to process lab requisitions and ensure tests were conducted. Despite this, the Director of Clinical Operations was unable to provide evidence of lab work that consistently matched the physician's orders. This inconsistency in obtaining the required laboratory tests led to the deficiency identified by the surveyors.
Failure to Adhere to Safe Food Practices in Kitchen
Penalty
Summary
The facility failed to adhere to safe food practices in its main kitchen, leading to potential contamination of food and beverage items intended for resident consumption. During an initial walkthrough, the surveyor observed several instances of non-compliance with the facility's food storage policy. In the reach-in refrigerator, there were unlabeled and undated food items, including five brown squares of cake or brownie-type food and seven pieces of pumpkin pie. The walk-in refrigerator contained a package of sliced cheese that was dry and open to air, a package of mozzarella cheese that was opened and undated, and a container of orange slices and chicken soup with use-by dates. Additionally, there were spoiled items such as tomatoes with black spots and gray fuzz, wilted mixed greens, and various vegetables with black spots and mushy textures. In the dry storage room, there were opened and undated containers of breadcrumbs, flour, and dry cereal, as well as undated packages of dinner rolls and loaves of bread. Interviews with the Food Service Director (FSD) and the Corporate Food Service Director revealed a lack of adherence to labeling and discarding guidelines. The FSD admitted to relying on delivery dates to determine the freshness of undated dinner rolls, while the Corporate Food Service Director acknowledged that expired and outdated foods should be discarded and foods should be dated once opened. The Administrator confirmed that the FSD is responsible for ensuring expired foods are discarded and food items are labeled when opened. These observations and interviews indicate a systemic failure to implement safe food practices, as outlined in the facility's policy and relevant regulations, potentially compromising the safety and sanitation of food served to residents.
Infection Control Deficiencies in EBP and Meal Service
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, leading to potential infection control issues. For one resident with a peripherally inserted central catheter (PICC) line, a nurse administered intravenous medication without wearing a gown, despite a sign indicating EBP was in effect. The nurse was unaware of the requirement to wear a gown during high-contact procedures, which could facilitate the transmission of multi-drug resistant organisms (MDROs). Another resident, who was admitted with an external dialysis catheter, was not placed on EBP, and there was no signage indicating the need for such precautions. Both nurses and the Director of Clinical Operations acknowledged that the resident should have been on EBP due to the increased risk of infection from the external catheter. Additionally, during meal service, staff placed soiled dishware back into carts with meals awaiting delivery, contrary to facility policy, posing another infection control concern.
Failure to Conduct Routine Bed Entrapment Inspections
Penalty
Summary
The facility failed to identify and minimize areas of possible entrapment in resident beds, specifically for a resident with a traumatic brain injury, history of falling, and muscle weakness. The facility did not conduct routine inspections on the resident's bed frame and mattress to identify possible areas of entrapment. Observations revealed significant gaps between the bed rails and the headboard and footboard, which were not assessed for entrapment risks. The Maintenance Director assumed that the large gaps would automatically pass the entrapment assessment and did not conduct a proper evaluation. The facility lacked policies or protocols to ensure periodic assessments of beds for entrapment risks. The Maintenance Director was unaware of the need to measure all beds, including those without side rails, for potential entrapment zones. The Administrator confirmed the absence of such protocols and acknowledged the need for the Maintenance Director to evaluate all beds for entrapment. The facility's failure to conduct comprehensive entrapment assessments and maintain proper documentation contributed to the deficiency.
Failure to File Grievance for Resident's Care Concerns
Penalty
Summary
The facility failed to file a grievance for a resident whose guardian expressed concerns about the resident's care. The resident, who was admitted with diagnoses including dementia, tracheostomy, diabetes, and seizures, was observed to be in a comatose state and dependent on staff for activities of daily living. The guardian reported finding the resident in unclean bedding, which was not addressed by the facility staff as required by their grievance policy. The facility's grievance policy mandates that any complaints should be documented and addressed promptly. However, the Social Worker did not file a grievance after being informed of the guardian's concerns about the resident's care. The Social Worker also failed to notify the nursing staff about these concerns, which could have led to immediate corrective actions. Observations by the surveyor confirmed the resident's unkempt condition, including unshaved facial hair and unclean bed linens. Interviews with facility staff revealed a lack of communication and adherence to the grievance policy. The Social Worker acknowledged not filing a grievance or informing the nursing staff, while the Director of Clinical Operations and the Administrator confirmed that a grievance should have been filed. The grievance was only documented after the Ombudsman contacted the facility, highlighting the delay in addressing the guardian's concerns.
Failure to Assess Abdominal Binder as Restraint
Penalty
Summary
The facility failed to properly assess and document the use of an abdominal binder as a potential restraint for a resident with a history of traumatic brain injury, falls, and muscle weakness. The resident, who was admitted in January 2023, was dependent on staff for activities of daily living and had a feeding tube. Despite the facility's policy requiring a pre-restraining evaluation and consent for restraint use, the resident's plan of care did not include documentation supporting the use of the abdominal binder, nor was there a consent from the resident's health care agent. Observations and interviews revealed that the resident was unable to self-release the abdominal binder, which was used to prevent the accidental removal of the PEG tube. The facility's Director of Clinical Operations confirmed that the use of restraints requires quarterly assessments and that the resident should be able to self-release the binder. However, the resident was observed to be unable to remove the binder on command, indicating a failure to comply with the facility's restraint policy and regulatory requirements.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident, admitted in October 2022, had diagnoses including emphysema, chronic obstructive pulmonary disease (COPD), and anxiety. Despite being cognitively intact and requiring assistance with activities of daily living, the MDS assessment dated November 8, 2024, incorrectly indicated that the resident did not require oxygen administration. However, a physician's progress note from November 1, 2024, documented the resident's chronic oxygen use at 2 liters per minute due to severe COPD. Additionally, the resident's Treatment Administration Record (TAR) for November 2024 showed consistent oxygen administration at 2 LPM every shift from November 1 to November 8, 2024. The resident's care plan, revised on November 21, 2024, also included oxygen settings as ordered. During an interview, the Director of Clinical Operations acknowledged that the MDS Nurse should have coded the oxygen use but failed to do so.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to several deficiencies. For one resident with severe cognitive impairment and a history of falls, the facility did not consistently ensure the bed was in the lowest position with fall mats on both sides, as ordered by the physician. Observations revealed that the bed was often at a regular height, and fall mats were either missing or improperly placed, exposing the resident to potential falls. Interviews with staff indicated a lack of awareness and communication regarding the physician's orders. Another resident with a history of suicidal ideation and severe cognitive impairment did not have a care plan addressing their mental health needs. Despite the resident's history and current mental health status, the facility failed to develop a plan of care to inform direct care staff of the resident's needs. Interviews with the social worker and the Director of Clinical Operations confirmed that a care plan should have been in place to address the resident's history of suicidal ideation. Additionally, the facility did not develop a care plan for a resident using psychotropic medications, including Ativan and Trazodone, despite the resident's diagnoses of dementia, depression, and psychosis. The care plan lacked focus, goals, and interventions for these medications. Furthermore, another resident with a traumatic brain injury and a history of falls did not have padded side rails as indicated in their care plan, which was intended to assist with skin integrity and prevent limbs from sliding through the side bars. Observations and staff interviews confirmed the absence of padded side rails, highlighting a failure to implement the care plan as documented.
Failure to Update Care Plans for Oxygen Therapy and Smoking Safety
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team (IDT) as required for two residents. For one resident, the care plan related to the oxygen flow rate for a tracheostomy was not updated to reflect the current physician's order. The resident, who was admitted with diagnoses including anoxic brain damage and chronic respiratory failure, was observed receiving oxygen at 4 liters per minute via a tracheostomy mask. However, the care plan still indicated an outdated setting of 2 liters per minute, despite a physician's order and progress note indicating the correct flow rate of 4 liters per minute. Another resident's care plan related to smoking safety was not updated to reflect the current practice. The resident, who was cognitively intact and required assistance with activities of daily living, was evaluated as able to smoke with supervision without protective equipment. However, the care plan still indicated the use of a smoking apron, which the resident and staff confirmed was never used. Observations confirmed that the resident smoked without a smoking apron, contrary to the outdated care plan. The facility's policies require that care plans be reviewed and updated by the IDT when there is a significant change in the resident's condition or at least quarterly. In both cases, the care plans were not revised to match the current assessments and practices, leading to discrepancies between the care provided and the documented care plans.
Failure to Repair Resident's Eyeglasses
Penalty
Summary
The facility failed to ensure that vision services were adequately provided for a resident with absolute glaucoma and an artificial left eye. The resident, who was admitted in March 2022, had moderately impaired vision and wore corrective lenses. Despite the resident's severely impaired cognition, as indicated by a score of 6 out of 15 on the Brief Interview for Mental Status exam, the facility did not make arrangements to repair the resident's broken eyeglasses. The resident's communication care plan included an intervention to ensure assistive devices like glasses were in place, but this was not followed through. Observations and interviews revealed that the resident was wearing broken glasses for an extended period, with the right-side arm of the glasses broken off. Nursing notes from August 2024 indicated a need for new glasses due to the risk posed by the broken pair, yet no referral was made for repair. The social worker and CNA were unaware of any actions taken to address the issue, and the Director of Clinical Operations confirmed that the ophthalmologist should have been contacted to issue a new pair of glasses. The lack of documentation and follow-up between August and December 2024 further highlights the facility's failure to address the resident's vision needs adequately.
Failure to Implement Pressure Ulcer Care Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions for pressure ulcer care for a resident, leading to a deficiency. The resident, who was admitted in September 2023 with diagnoses including diabetes, depression, and failure to thrive, had one Stage 3 pressure ulcer and two Stage 4 pressure ulcers. Despite the physician's order for Prevalon boots and the elevation of the resident's heels to reduce pressure, these interventions were not consistently implemented. Observations by the surveyor on multiple occasions revealed the resident's right heel was directly on the bed extender and not elevated, and the Prevalon boots were not provided as ordered. Interviews conducted during the survey confirmed the lack of implementation of the care plan interventions. The resident reported not receiving the boots, and a CNA confirmed that the resident did not wear boots and had wounds on their feet. The Director of Clinical Operations acknowledged that nursing should implement care plan interventions and physician's orders to promote wound healing, indicating a lapse in following the prescribed care plan for the resident.
Failure to Document and Implement Hand Splint Schedule
Penalty
Summary
The facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for a resident. Specifically, the facility did not obtain physician's orders for the use of bilateral hand splints as recommended by the Occupational Therapist. The resident, who was admitted with diagnoses including anoxic brain damage and chronic respiratory failure, was observed wearing bilateral hand splints on multiple occasions. However, there was no documentation in the resident's physician's orders or care plan to support a splint wearing schedule. Interviews with facility staff revealed a lack of clarity and consistency regarding the resident's splint wearing schedule. A Certified Nurse Assistant and two nurses were unsure about the duration and timing for the application of the hand splints. The Director of Clinical Operations acknowledged that splint use should be care planned with a specific schedule, but confirmed that no such orders were present in the electronic health record. This lack of documentation and communication led to the deficiency in providing appropriate ROM care for the resident.
Failure to Monitor and Document Resident's Weight Changes
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with end-stage renal disease who was dependent on dialysis. The resident was admitted in November 2024 and had a care plan indicating they were underweight with a low BMI. The facility's policy required weekly weight checks for new admissions, but the resident's medical record showed only one weight recorded on 11/20/24, with no further weights documented. The resident's dialysis communication book showed significant weight fluctuations, but these were not reviewed or evaluated by the facility staff. The facility's failure to obtain and document weights as ordered led to a lack of identification and response to significant weight changes. The resident's dialysis communication book indicated a 32.09% weight gain over 19 days and a 20.29% weight loss over 8 days, but these changes were not addressed. The December 2024 Medication Administration Record (MAR) failed to show a weight obtained on 12/24/24, and although a weight was signed as obtained on 12/31/24, it was not documented in the medical record. Additionally, the resident refused to be weighed on 1/7/24, and no follow-up weight was obtained. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's weight management. The dietitian was unaware of the resident's refusal to be weighed and had not reviewed the dialysis communication book. Nurse #7 was unsure of the process for handling weight refusals and did not enter dialysis weights into the electronic medical record. The Director of Clinical Operations stated that post-dialysis weights should be evaluated and entered into the medical record, but this was not done for the resident. The dietitian later acknowledged that the significant weight change noted on 12/9/24 should have been evaluated and addressed, but it was not.
Failure to Adhere to Respiratory Care Orders
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for a resident diagnosed with emphysema, COPD, and anxiety. The resident was observed receiving oxygen at 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was noted on multiple occasions, and the facility's policy on oxygen administration was not adhered to. Interviews with nursing staff and the Director of Clinical Operations confirmed that oxygen settings should align with the physician's order, which was not the case for this resident. Additionally, the facility did not change the nebulizer machine tubing as ordered by the physician. The resident expressed concerns about the nebulizer's effectiveness, and the surveyor observed outdated tubing with residual liquid in the nebulizer cup. The physician's order required weekly changes of the nebulizer and oxygen tubing, which was not followed, as evidenced by the Treatment Administration Record. The Director of Clinical Operations acknowledged that the tubing should have been changed according to the physician's orders, and the failure to do so was incorrectly documented as the resident sleeping.
Failure to Develop Trauma-Informed Care Plans
Penalty
Summary
The facility failed to develop trauma-informed care plans for three residents with histories of trauma, including sexual abuse and PTSD. Resident #2, admitted with diagnoses of Adult Sexual Abuse and Dementia, did not have a trauma assessment or care plan in place, despite hospital discharge paperwork indicating a new diagnosis of Adult Sexual Abuse. Interviews with facility staff confirmed that a trauma assessment and care plan should have been developed, and staff should have been educated on potential triggers for re-traumatization. Similarly, Resident #73, with a history of suicidal ideation and adult physical and sexual abuse, lacked a trauma assessment and care plan. The resident's medical record did not reflect any trauma-informed interventions, and staff interviews revealed that such a care plan was expected. Resident #78, diagnosed with PTSD and anxiety disorder, also did not have a PTSD care plan with specific triggers and interventions. The Director of Clinical Operations acknowledged the necessity of a resident-specific care plan for those with PTSD.
Improper Implementation of Side Rails for Resident
Penalty
Summary
The facility failed to ensure that bilateral side rails were implemented in accordance with the care plan for a resident who was admitted with diagnoses including traumatic brain injury, history of falling, and muscle weakness. The resident was observed with side rails in the middle of the bed, which were not specified in the care plan or physician's order. The side rail consent form was incomplete, lacking a date of discussion, last review date, and details on risks and benefits. The consent form was signed by the resident's representative but not checked off as consenting. The care plan indicated the use of grab bars as an enabler for bed mobility, but the side rails observed were not grab bars. Interviews with facility staff revealed inconsistencies in the understanding and implementation of the side rail use. A CNA stated that the resident was totally dependent for care and had side rails to keep them in bed, while the Director of Clinical Operations acknowledged that the side rails should be based on the assessment and care plan. The facility lacked a policy for side rails, contributing to the deficiency. The surveyor's observations and staff interviews highlighted the facility's failure to adhere to proper procedures for side rail use, as outlined in the care plan and consent documentation.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as observed during a survey. One nurse made 10 errors out of 43 medication administration opportunities, resulting in a 20.93% error rate. This affected two residents, Resident #34 and Resident #77. Resident #34, who has diagnoses including diabetes, Alzheimer's, and high blood pressure, was observed receiving some of their prescribed medications at the incorrect time and missing several others entirely. Specifically, medications such as Glipizide, Lokelma, Miralax, Atenolol, Namanda, B-12, and Ferrous Sulfate were not administered as ordered. Similarly, Resident #77, with diagnoses including heart disease, adult failure to thrive, and high blood pressure, was also affected by medication administration errors. The nurse administered some medications correctly but failed to give Amlodipine Besylate and Metoprolol Succinate Extended Release as prescribed. The Director of Clinical Operations confirmed that all scheduled medications should be administered at the time ordered, highlighting the facility's failure to adhere to its medication administration policy.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional standards of practice. On one occasion, a medication nurse gave the keys, including narcotic keys, to an unassigned staff nurse, allowing that nurse access to their medication cart. This occurred while the nurse was assisting a resident, with their back turned to the cart, which was accessed by the unassigned nurse. The Director of Clinical Operations confirmed that it is expected for nurses to maintain control of their own medication cart keys and not allow other nurses to access the cart. Additionally, the facility failed to secure a medication cart on one of the nursing units. On two separate occasions, surveyors observed and accessed an unlocked medication cart in the 3rd floor unit dining room while the assigned nurse was across the room attending to residents. The nurse acknowledged that the medication cart should always be locked when not attended. The Director of Clinical Operations reiterated the expectation that medication carts be locked when unattended.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for Resident #85, who was admitted with diagnoses including kidney disease, heart disease, and alcohol use. A physician's order from January 2024 indicated that the resident may have dental consults. On December 6, 2024, a progress note documented that the resident experienced mouth discomfort and had redness and inflammation on the gums. A physician's assistant was notified and prescribed Amoxicillin, and the resident was to be seen by a dentist when they arrived at the facility. However, the medical record did not show that the resident was seen by a dentist on December 10, 2024, or any time thereafter. During an interview, the Director of Clinical Operations stated that a dental consult should have been obtained for residents with gum swelling and mouth pain.
Inaccurate Documentation in Medical Records
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for two residents, leading to deficiencies in care documentation. For one resident, the Treatment Administration Record (TAR) inaccurately documented that the bed was in the lowest position and that fall mats were in place, as per the physician's orders. Observations revealed that the bed was often at a regular height, and the fall mats were either missing or improperly positioned, exposing the resident to potential harm. Interviews with the Certified Nursing Assistant (CNA) and the nurse indicated a lack of awareness and expectation that the documentation should reflect the actual conditions. For another resident, the Medication Administration Record (MAR) failed to accurately document the administration of medications. The MAR showed that several doses of medications were not signed off as administered on multiple occasions, with no indication in the clinical progress notes as to why. An interview with the nurse responsible revealed that the medications were administered, but she forgot to sign them off, citing the resident's preference to take medications with food as a reason for the oversight. The Director of Clinical Operations expressed the expectation that both the TAR and MAR should accurately reflect the care provided to residents. The inaccuracies in documentation for both residents highlight a failure in maintaining accurate medical records, which is essential for ensuring proper care and compliance with professional standards.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information at the start of each shift. Observations by the surveyor on multiple occasions revealed that the staffing information posted at the front of the facility was outdated. On January 6, 2025, both in the morning and evening, the staffing data displayed was dated December 25, 2024. Similarly, on January 8 and 9, 2025, the posted staffing information was dated January 7, 2025, indicating a failure to update the information daily. Interviews with the Scheduling Coordinator and the Administrator confirmed that the responsibility for printing and posting the staffing data was not being executed as required, leading to the deficiency.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to follow physician's orders for the prevention of pressure ulcer development for a resident diagnosed with adult failure to thrive and severe protein-calorie malnutrition. The resident, who was cognitively intact and totally dependent for all activities of daily living, was observed multiple times without the prescribed heel booties and with an air mattress set incorrectly at 200 lbs. Despite physician orders for heel booties to be worn from 8 am to 8 pm and a pressure redistribution mattress to be checked for correct settings every shift, these measures were not implemented. The resident subsequently developed a reddened area on the left heel and a deep tissue pressure injury on the right heel, which were not previously documented in the weekly skin evaluations or known to the nursing staff until observed by the surveyor. Interviews with the resident and staff revealed that the resident had been experiencing ongoing heel pain and had not been provided with the heel booties as ordered. The CNA responsible for the resident was unaware of any heel issues and stated that only nurses could adjust the air mattress settings. The nurse in charge was also unaware of the resident's current weight and incorrectly believed the air mattress setting was appropriate. The Director of Nursing confirmed that the air mattress should be set according to the resident's weight and that physician orders for heel booties should have been followed. The failure to implement these preventive measures resulted in the development of pressure injuries on the resident's heels.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents on three nursing units. Multiple residents reported that there were no activities available, except occasionally on Sundays. Observations on several dates confirmed that scheduled activities were not being held as indicated on the posted Activity Calendar. The facility did not have an Activity Director since December 2023, and the Activity Assistant had resigned in November 2023. Certified Nursing Aids (CNAs) were occasionally asked to provide activities, but this was not consistent or sufficient to meet the residents' needs. Interviews with staff, including CNAs and a nurse, confirmed the lack of activities. The Administrator acknowledged the absence of activity staff and the lack of a specific Quality Assurance Performance Improvement (QAPI) plan to ensure the continuation of the activity program. Observations on multiple dates showed that scheduled activities were not taking place, and staff assigned to perform activities were not engaging residents. The facility's failure to provide a structured activity program resulted in a deficiency in meeting the residents' physical, mental, and psychosocial well-being needs.
Failure to Provide Smoking Alternatives During Covid Outbreak
Penalty
Summary
The facility staff failed to honor the smoking preferences of two residents during a Covid outbreak. Resident #15, who has chronic obstructive pulmonary disease (COPD), cardiomyopathy, and chronic ischemic heart disease, was admitted in October 2020. Despite being cognitively intact, as indicated by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), Resident #15 was not allowed to smoke for three days due to the outbreak. The resident's care plan, last revised in October 2022, indicated a need for supervised smoking, but no alternative measures were provided during the outbreak. Interviews with the staff, including Nurse #3 and the Assistant Director of Nursing (ADON), revealed a lack of awareness and a clear plan for managing smokers during the outbreak. The ADON later mentioned a plan to use N95 masks and have a Certified Nursing Assistant (CNA) assist smokers, but this was not implemented for Resident #15, who missed scheduled smoking times. Similarly, Resident #79, admitted in May 2021 with diagnoses including cerebral infarction, dysphagia, and hemiplegia, was also affected. The resident, who scored 13 out of 15 on the BIMS, indicating cognitive intactness, had not been allowed to smoke since the outbreak began. The resident's care plan, last revised in May 2023, also indicated a need for supervised smoking. Interviews with Resident #79 and Nurse #11 confirmed that no alternative smoking plan was in place during the outbreak. The Administrator acknowledged the absence of a set policy or alternative plan for smokers during the Covid outbreak, leading to frustration and unmet needs for Resident #79.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for three residents, leading to deficiencies in their care. For Resident #20, who has severe cognitive impairments and is at nutritional risk, the facility did not provide the required supervision during meals. Despite a care plan indicating the need for continuous supervision and cueing to complete meals, the resident was observed eating alone multiple times without staff supervision. Interviews with staff revealed a misunderstanding of the resident's needs, with one nurse incorrectly stating that the resident did not require supervision for meals, contrary to the care plan and the Director of Nursing's expectations. For Resident #70, who has moderate cognitive impairments and a history of falls, the facility failed to implement a scoop mattress as part of the fall care plan. Despite a fall incident resulting in a fracture and a subsequent investigation recommending a scoop mattress, the care plan did not include this intervention. The Director of Nursing acknowledged that the resident's healthcare proxy had declined the scoop mattress without proper invocation, meaning the resident should have been offered the intervention directly. Resident #255, who has moderate cognitive impairments and a history of depression, did not have a care plan addressing suicidal ideation. The resident had expressed suicidal thoughts during a hospital stay, as documented in discharge paperwork. However, the facility did not develop a care plan to address these mental health concerns. The social worker confirmed that a care plan should have been completed for any resident expressing suicidal ideation, but this was not done for Resident #255.
Failure to Adhere to Professional Standards of Care
Penalty
Summary
The facility failed to ensure that four residents received care and treatment in accordance with professional standards. For one resident with a peripherally inserted central catheter (PICC), the facility did not take a baseline measurement upon admission, nor did they monitor the condition of the insertion site or the length of the catheter exiting the body. The Director of Nursing (DON) and a nurse confirmed the importance of these measures, but no policy was found regarding PICC line monitoring. Additionally, the facility did not follow a physician's recommendation for a hand surgeon consult for another resident with hand contractures, despite the resident expressing a desire for treatment options and the physician's notes indicating the need for a consult. Another resident receiving hospice services had recommendations from a hospice nurse practitioner for medications to manage anxiety and pain, but these recommendations were not reviewed or implemented. The DON was unaware that the hospice recommendations had not been reviewed. Lastly, a diabetic resident was given an incorrect supplement during a medication pass because the facility had run out of the prescribed Glucerna. The nurse administered Med Pass 2.0 instead, which contains added sugar and could impact the resident's blood sugar levels. The DON and the dietician confirmed the supply issue and stated that an unsweetened alternative should have been provided. These deficiencies highlight the facility's failure to adhere to professional standards of care, including proper monitoring and documentation, following physician recommendations, and ensuring the correct administration of prescribed supplements. The lack of adherence to these standards resulted in inadequate care for the residents involved.
Failure to Provide Adequate Care and Communication Services
Penalty
Summary
The facility failed to assess and treat a resident after a decline in functional status. Resident #68, admitted with diagnoses including dysphagia and reduced mobility, had not received occupational or physical therapy services since November 2023. Despite being dependent on assistance for various activities of daily living, the resident expressed a desire for rehab services, which had not been provided. The Rehab Director was unaware of the resident's decline in functional status until informed by the surveyor, indicating a lapse in communication and follow-up care within the facility. The facility also failed to provide appropriate communication services for Resident #255, who has a language barrier and requires an interpreter to communicate with staff. Despite the care plan indicating the need for an interpreter, staff relied on the resident's daughter for communication and did not use the language line. This resulted in the resident experiencing agitation and frustration due to the inability to communicate effectively with staff. Observations showed the resident in distress multiple times, with staff unable to alleviate the situation due to the communication barrier. Additionally, the facility did not provide adequate assistance with meals for two residents. Resident #28, who requires substantial assistance with eating, was observed eating alone without supervision on multiple occasions. Similarly, Resident #81, who has a history of choking and requires supervision during meals, was also left alone while eating. Despite the care plans indicating the need for assistance, staff did not provide the necessary support, leading to potential risks for these residents.
Failure to Change Oxygen Tubing and Clean Concentrator Filter
Penalty
Summary
The facility failed to change oxygen tubing according to physician's orders for three residents and did not change an oxygen concentrator filter for one resident. Resident #31, who has chronic respiratory failure and emphysema, was observed using oxygen tubing dated three weeks prior, despite orders to change it weekly. The Medication Administration Record indicated the tubing was changed on two specific dates, but not weekly as required. The Director of Nursing confirmed that the tubing should be changed weekly according to the physician's orders. Resident #20, with severe cognitive impairments and chronic obstructive pulmonary disease, was observed using oxygen tubing labeled with a date that did not comply with the weekly change order. Nurse #2 was unsure of the frequency or responsibility for changing the tubing. The Director of Nursing stated that orders were recently changed to ensure tubing is changed and dated every Wednesday night. Resident #48, who is cognitively intact and has chronic obstructive pulmonary disease, was observed with an undated oxygen tubing and a concentrator filter coated with dust. The tubing was later dated, but the filter remained uncleaned. Nurse #7 and the Director of Nursing confirmed that the tubing and filter should be maintained according to the physician's orders.
Failure to Complete and Document Annual Competencies for Nursing Staff
Penalty
Summary
The facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility did not complete and document annual competencies for six out of six certified nursing assistants (CNAs) and six out of six licensed nurses whose education records were reviewed. This deficiency was identified through interviews, facility assessment review, and in-service documentation review. The Board of Registration in Nursing defines competency as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse and for the delivery of safe nursing care in accordance with accepted standards of practice. The Facility Assessment Tool, last revised on an unspecified date, indicated that general orientation, monthly in-services, and care-related clinical competencies should be completed annually and as needed based on the case load. However, the education records provided by the Administrator showed that the required annual competencies for 2023 were not completed. During interviews, the Administrator acknowledged the outdated Facility Assessment Tool, and the Assistant Director of Nursing (ADON) admitted that staff education and competencies were not up to date and that efforts were underway to complete the required competencies.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for six of six sampled CNAs. During a review of six CNA employee records, it was noted that none of the sampled CNAs received their annual performance reviews. In an interview with the Director of Nursing (DON) and the Administrator, it was revealed that the responsibility for annual performance reviews lies with Corporate, and there was uncertainty about who was currently completing them. The DON mentioned she would check with Corporate regarding the annual performance reviews.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to provide a physician-ordered medication for a resident diagnosed with anxiety and depression. On 1/31/24, Nurse #1 did not administer Trazodone to Resident #64 as prescribed. Despite the medication being available in the emergency medication supply, Nurse #1 did not check the emergency kit and instead documented the medication as unavailable and contacted the pharmacy for delivery. The pharmacy delivery manifest indicated that the medication had been delivered to the facility on 1/24/24. During an interview, Nurse #1 acknowledged that she should have checked the emergency kit for the medication. The Director of Nursing confirmed that the medication was available in the emergency kit and that Nurse #1 should have checked it. The DON also noted that the medication had been recently delivered to the facility according to the pharmacy delivery manifest.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5 percent. During observations, three out of four nurses made four errors in 38 opportunities, resulting in a medication error rate of 10.53%. These errors impacted three residents. Nurse #6 administered only one tablet of metformin 500mg to Resident #90 instead of the prescribed two tablets. Nurse #9 gave a multivitamin with minerals to Resident #27 instead of the regular multivitamin as prescribed. Nurse #8 administered midodrine to Resident #64 despite the resident's systolic blood pressure being greater than 110, contrary to the physician's orders, and also mistakenly thought she had given thiamine instead of midodrine. Interviews with the involved nurses revealed that they acknowledged their mistakes. Nurse #6 admitted he should have given two tablets of metformin according to the physician's orders. Nurse #9 confirmed she was supposed to give the regular multivitamin and not the one with minerals. Nurse #8 admitted she should have read the directions clearly and not administered midodrine when the resident's systolic blood pressure was greater than 110. The Director of Nursing stated that nurses are expected to read the orders thoroughly and administer medications correctly.
Failure to Adhere to Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the facility did not adhere to physician orders for administering Midodrine HCL to a resident with a history of falling and anemia. The physician's orders specified that the medication should be held if the resident's systolic blood pressure was greater than 110. However, the resident received the medication for 28 out of 31 days in January 2024, despite blood pressure readings being outside the specified parameters. On 1/31/24, a surveyor observed Nurse #8 administering Midodrine to the resident after recording a blood pressure reading of 125/71, which was above the threshold set by the physician. During interviews, Nurse #8 acknowledged that the medication should not have been administered, and the Director of Nursing confirmed that the expectation was for nurses to follow physician orders accurately. This failure to adhere to the prescribed parameters resulted in a significant medication error for the resident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,324 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Newton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lasell House | 1.6 mi | ★★★★★ | 1 | 0 |
| Maristhill Nursing & Rehabilitation Center | 1.8 mi | ★★★★★ | 24 | 0 |
| Care One At Newton | 2 mi | ★★★★★ | 8 | 0 |
| Stone Rehabilitation And Senior Living | 2.6 mi | ★★★★★ | 5 | 0 |
| Presentation Rehab And Skilled Care Center | 2.6 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.