Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Wakefield Health Care Center during CMS and state inspections, most recent first.
The facility did not attempt or document required Gradual Dose Reductions (GDRs) for antipsychotic medications in two residents with dementia and behavioral disturbances, and allowed as-needed Haldol to be administered to another resident beyond the 14-day limit without proper evaluation. These actions were not in accordance with facility policy or federal regulations regarding psychotropic medication use.
Staff failed to secure medications by leaving them unattended on the medication cart, leaving the cart unlocked, and leaving the narcotic key in the lock without supervision. Additionally, medication aides did not properly supervise two residents during medication administration, relying only on verbal confirmation that medications were taken. The DON confirmed these practices were not in line with facility policy.
The facility did not perform or document required neurological assessments after unwitnessed falls for two residents, including one with severe cognitive impairment and on anticoagulant therapy. Despite facility policy mandating specific post-fall neurological checks and documentation, multiple assessments were missed or incomplete following several incidents. Interviews with staff and the DON confirmed that the established protocol was not followed.
Two residents with dementia, depression, and anxiety were prescribed multiple psychoactive medications, including Lorazepam, Mirtazapine, Zoloft, Lexapro, and Trazadone, without any documented attempts or consideration of Gradual Dose Reductions (GDRs) over the past year. Facility policy and federal regulations required GDRs to be attempted unless clinically contraindicated, but the DON confirmed that no such actions were taken or documented.
The facility failed to manage psychotropic medications properly for several residents. A resident received PRN antipsychotic medication beyond the 14-day limit without physician review. Another resident's gradual dose reduction for Clonazepam was delayed by 57 days despite a recommendation. Additionally, a resident continued to receive PRN Lorazepam without a clinical rationale for over three months.
The facility failed to implement enhanced barrier precautions for a resident with non-healing pressure ulcers and did not adhere to standard precautions for hand hygiene and glove use. Staff did not wash hands or change gloves appropriately, and reusable equipment was not cleaned between uses. The Director of Nursing and Administrator confirmed these deficiencies.
The facility failed to provide two residents with the required Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage, which are necessary to inform them of the discontinuation of Medicare Part A coverage and their right to appeal. There was no documented evidence that these notices were given in a timely manner, nor were there records of the residents' decisions regarding appeals or financial responsibility. Interviews confirmed the notices were not received before the services ended.
The facility failed to protect residents from potential abuse, as a staff member accused of abuse was allowed to continue working their shift, contrary to policy. Two residents with cognitive impairments were involved, with one case reported to Adult Protective Services. The facility's response did not align with their policy, potentially compromising resident safety.
The facility failed to timely report and investigate two incidents involving residents. One resident with severe cognitive impairment eloped, and the report was delayed beyond the required timeframe. Another resident with Alzheimer's dementia fell, sustaining a head injury, but no written investigation was completed or submitted. Interviews confirmed these deficiencies.
A facility failed to ensure appropriate use of antibiotics for a resident, who was on long-term Bactrim for chronic UTIs without a specified duration or supporting documentation. The resident's care plan lacked an indication for the antibiotic, and the DON confirmed the order was for palliative care without a stop date.
A facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received omeprazole nearly two hours late, after breakfast, contrary to the prescribed time. Another resident's insulin was administered without expelling air from the pen, risking an inaccurate dose. Both errors were confirmed by the RN involved.
A resident's insulin medication was incorrectly labeled, indicating a dosage of 11 units instead of the prescribed 7 units. The facility's policy requires proper labeling and verification before administration, but the label lacked a pink sticker to indicate a change in dosage, which had been in effect for over two months. An RN confirmed the discrepancy during an observation.
The facility failed to conduct required state Nurse Aide registry checks for two employees, Housekeeper-M and Transportation Aide-L, before their employment, violating policy and state regulations. This oversight, confirmed by a business office staff member, had the potential to affect all 33 residents, as it could allow individuals with a history of misconduct to work in the facility.
Failure to Ensure Gradual Dose Reductions and Timely Review of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by both facility policy and federal regulations. For two residents with dementia and behavioral disturbances, the facility did not attempt or document Gradual Dose Reductions (GDRs) for their prescribed Seroquel, despite these residents having been on the medication since admission. The care plans and medication administration records for these residents showed ongoing use of antipsychotic medication without evidence of GDRs being addressed or attempted over the previous year. The Director of Nursing confirmed that no GDRs had been attempted or documented for these residents during this period. Additionally, another resident with severe cognitive impairment and multiple diagnoses, including dementia, heart disease, anxiety, and depression, was prescribed Haldol as needed for agitation, aggression, or restlessness. The as-needed order for Haldol was continued and administered beyond the 14-day limit without documented evaluation by the primary care provider for appropriateness, as required by facility policy. The Director of Nursing confirmed that the medication was administered past the 14-day limit. These actions were inconsistent with the facility's own policy and regulatory requirements regarding the use and review of psychotropic medications.
Failure to Secure Medications and Supervise Administration
Penalty
Summary
Facility staff failed to ensure the safe storage and supervision of medications in accordance with professional standards and facility policy. Observations revealed that medications were left unattended on top of the medication cart, and the cart itself was left unlocked and unsupervised in multiple instances. The key to the narcotic lock box was left in the lock with no nurse present, and staff were observed walking away from the cart while it remained accessible to others. These actions were in direct violation of the facility's own policies, which require all drugs and biologicals to be stored in locked compartments and not left unattended. Additionally, staff did not properly supervise residents during medication administration. On several occasions, medication aides placed medication cups in front of residents and walked away without ensuring the medications were taken, relying solely on verbal confirmation from the residents. Interviews with staff confirmed that residents were not supervised during medication administration, and the Director of Nursing acknowledged that medications should be locked and residents should not receive medications without staff supervision. These failures were observed among a sample of 19 residents, with a facility census of 31.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological assessments as required by its own policy following unwitnessed falls for two residents. The policy, last revised in October 2010, mandates neurological checks after unwitnessed falls, falls with suspected head injury, or when indicated by resident condition. These checks include assessments of orientation, speech, vital signs, pupil reactions, and motor ability, and must be documented in the resident's medical record with specific timing and details. Staff interviews confirmed that the protocol was not followed, and the Director of Nursing acknowledged the lapses. One resident with severe cognitive impairment, multiple diagnoses including heart disease and dementia, and on anticoagulant therapy, experienced several unwitnessed falls. For each incident, required neurological assessments at specified intervals (every 15 minutes, 30 minutes, hourly, and per shift) were missing from the documentation. The resident's care plan identified them as high risk for falls and in need of extensive assistance, yet the facility failed to document or perform the required post-fall neurological checks on multiple occasions. Another resident, cognitively intact but with multiple medical conditions and at risk for falls, also experienced unwitnessed falls. After these incidents, the facility failed to complete and document neurological assessments and vital signs as required. Incident reports and post-fall assessment forms showed missing or incomplete documentation for the required checks. The DON confirmed that staff did not follow the facility's neurological assessment protocol after these falls.
Failure to Attempt Gradual Dose Reductions for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications by not attempting or addressing Gradual Dose Reductions (GDRs) for their psychoactive medications. Facility policy required that behavior interventions be evaluated before using psychotropic medications, and that GDRs be attempted unless clinically contraindicated, in accordance with federal regulations. For both residents, who had diagnoses including dementia with behavioral disturbances, depression, and anxiety, there was no evidence in their medical records that GDRs were attempted or considered over the previous year for medications such as Lorazepam, Mirtazapine, Zoloft, Lexapro, and Trazadone. Record reviews showed that one resident was receiving Mirtazapine, Zoloft, and Lorazepam, while another was on Lexapro, Lorazepam, and Trazadone, with no documentation of GDRs being addressed. The Director of Nursing confirmed during interview that no GDRs had been attempted or addressed for these residents' psychoactive medications in the past year, which was inconsistent with both facility policy and regulatory requirements.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to regulations regarding the administration and management of psychotropic medications for several residents. For Resident 12, the facility did not ensure that an as-needed (PRN) antipsychotic medication order was limited to 14 days in duration. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and depression, received Haloperidol without a stop date, and the medication was administered on multiple occasions beyond the 14-day limit without a physician's review. Resident 18, diagnosed with anxiety disorder, depression, manic depression, schizophrenia, and diabetes, was prescribed Clonazepam for anxiety. Despite a recommendation from a Nurse Practitioner to reduce the dosage due to potential tolerance, the facility did not implement the new order for a gradual dose reduction until 57 days later. This delay occurred even though the Primary Care Provider had signed off on the recommendation. For Resident 25, who had severe cognitive impairment and diagnoses including Alzheimer's disease and depression, the facility failed to provide a clinical rationale for the continued use of PRN Lorazepam. Despite recommendations from the Consultant Pharmacist to re-evaluate the medication and determine a duration date, the facility continued to administer the medication without documented justification for over three months.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with non-healing pressure ulcers, as required by their policy. Despite the resident's ongoing pressure ulcers, there was no signage or additional personal protective equipment (PPE) available in the resident's room to indicate EBP was in place. A nursing assistant confirmed that the resident had not been placed on EBP, and the Director of Nursing and Administrator acknowledged that the resident should have been on EBP due to the non-healing pressure ulcers. Additionally, the facility did not adhere to standard precautions regarding hand hygiene and glove use. Observations revealed that staff did not wash hands or change gloves at appropriate intervals during resident care, leading to potential cross-contamination. For instance, a medication assistant handled soiled linens without proper bagging and transported them through the facility, and another staff member used the same gloves for multiple tasks without changing them, including handling clean items after touching soiled ones. The facility also failed to properly clean reusable equipment between resident uses. A Hoyer lift was used on multiple residents without being cleaned in between, as confirmed by staff interviews. The Director of Nursing and Administrator confirmed that soiled linens should be bagged, and equipment like the Hoyer lift should be cleaned between uses to prevent cross-contamination.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide two residents, identified as Resident 5 and Resident 18, with the necessary Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage, which are required by the Centers for Medicare & Medicaid Services (CMS) regulations. These notices are crucial for informing residents or their representatives about the discontinuation of Medicare Part A coverage, potential financial responsibilities, and their right to appeal the decision. The facility's policy mandates that the ABN be given at least 48 hours in advance of any services likely to be denied by Medicare, and it must include specific details such as the resident's name, service description, reason for denial, estimated costs, and options for the resident to choose regarding the services. However, there was no documented evidence that these notices were provided to the residents or their representatives in a timely manner, nor was there any record of their decision to appeal or accept financial responsibility. For Resident 5, the skilled care services were no longer covered beginning on April 27, 2024, but there was no evidence of the resident or representative's decision regarding the appeal or billing options, nor was there a signature indicating receipt of the notice. Similarly, for Resident 18, the skilled care services ended on February 20, 2024, without documented evidence of the resident or representative's receipt and acknowledgment of the notice. Interviews with the representatives of both residents confirmed that they did not receive the necessary forms before the services ended. Additionally, a Business Office staff member confirmed that there was no verification of the notices being provided to the representatives before the service end dates, and no documented evidence of the residents' choices regarding continued services or appeals.
Failure to Protect Residents from Alleged Abuse
Penalty
Summary
The facility failed to protect residents from potential abuse, as evidenced by an incident involving two residents and an allegation of staff-to-resident abuse. The facility's policy on abuse, neglect, and misappropriation outlines procedures for handling such allegations, including immediate removal of the accused staff from the facility and ensuring the resident's protection. However, in this case, the accused staff member was allowed to continue working for the remainder of their shift, although they were restricted from entering the rooms of the residents who made the accusations. This decision was confirmed by both the LPN and the Administrator, indicating a failure to adhere to the facility's policy and adequately protect all residents. Resident 2, who had moderate cognitive impairment and required extensive assistance with daily activities, was involved in the incident, but there was no documentation in their progress notes regarding the alleged incident. Resident 5, who had severe cognitive impairment and required substantial assistance, was the subject of a verbal abuse allegation reported to Adult Protective Services. Despite the serious nature of these allegations, the facility's response did not align with their policy, as the accused staff member was not immediately removed from the facility, potentially compromising the safety of all residents.
Failure to Timely Report and Investigate Incidents
Penalty
Summary
The facility failed to complete and submit timely investigations for two separate incidents involving residents. In the first case, a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's Disease and dementia, eloped from the facility. The incident occurred on 8/27/24, but the report was not submitted to the State Agency until 9/5/24, missing the required five working days deadline. The Director of Nursing confirmed the delay in reporting during an interview. In the second incident, another resident with Alzheimer's dementia and severe cognitive impairment experienced a fall with injury. The resident fell backward, striking their head on a dresser, resulting in profuse bleeding and requiring emergency room evaluation. Although Adult Protective Services were notified, the facility did not complete or submit a written investigation to the State Agency. Interviews with the Director of Nursing and the Administrator confirmed the lack of a written investigation for this incident.
Failure to Ensure Appropriate Use of Antibiotics
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, specifically concerning the long-term use of an antibiotic for one resident. The facility's policy on Antibiotic Stewardship, reviewed in June 2024, aimed to monitor and promote the appropriate use of antibiotics, requiring prescribers to provide complete orders including drug name, dose, frequency, duration, route, and indications of use. However, for Resident 18, there was an order for Bactrim Double Strength to be taken daily for chronic urinary tract infections without a specified duration or supporting documentation for clinical use based on laboratory results. Resident 18's Minimum Data Set (MDS) indicated multiple diagnoses, including anxiety, depression, diabetes, manic depression, and schizophrenia, and the resident was receiving several medications, including an antibiotic, daily. The resident's care plan did not reflect an active or chronic infection or an indication for the long-term use of the antibiotic. During an interview, the Director of Nursing confirmed that the resident was on a prophylactic antibiotic, ordered by Hospice for palliative care, but there was no specified stop date or duration for its continued use.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by observations, record reviews, and interviews. During the administration of 28 medications, two errors were identified, resulting in a medication error rate of 7.14%. These errors affected two of the four sampled residents. The first error involved Resident 4, who was prescribed omeprazole 40 mg to be taken 60 minutes before meals at 7:30 AM. However, the medication was administered by RN-B at 9:25 AM, nearly two hours after the prescribed time, and after the resident had already eaten breakfast. The second error involved Resident 23, who was prescribed Novolog FlexPen insulin, 7 units subcutaneously, to be administered three times a day with meals. RN-B failed to follow the manufacturer's instructions for preparing the insulin pen, which required expelling 2 units of air before administering the dose. Instead, RN-B directly administered the 7 units without expelling air, potentially leading to an inaccurate dose. Both errors were confirmed through interviews with RN-B, who acknowledged the deviations from the prescribed procedures.
Incorrect Insulin Labeling for a Resident
Penalty
Summary
The facility failed to ensure that an insulin medication was labeled correctly for one of the sampled residents. The facility's policy on the storage of medications, which was reviewed in April 2024, mandates that drug containers with missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storage. Additionally, the policy on administering medications requires the individual administering the medication to check the label three times to verify the right resident, medication, dosage, time, and route of administration before giving the medication. During an observation, a registered nurse (RN) administered insulin to a resident using a Novolog FlexPen. The label on the insulin indicated a dosage of 11 units to be given subcutaneously three times a day, 15 minutes before a meal. However, the RN administered 7 units, as per the physician's order recorded in the Medication Administration Record (MAR), which was correct. The RN confirmed that the label on the medication was incorrect and should have had a pink sticker to alert staff of a change in the medication instruction, which had occurred over two months prior. The absence of this sticker was confirmed during the observation and interview with the RN.
Failure to Conduct Required Nurse Aide Registry Checks
Penalty
Summary
The facility failed to complete the required state Nurse Aide registry checks for two of the five sampled employees, which is a violation of the facility's policy and state regulations. The policy mandates that the facility must not employ individuals who have been found guilty of abuse, neglect, exploitation, or misappropriation of property, and requires background checks to be conducted prior to or at the time of employment. However, upon review, it was found that the facility did not check the state Nurse Aide registry for Housekeeper-M, hired on March 18, 2024, and Transportation Aide-L, hired on May 15, 2024, for any negative findings related to abuse, neglect, exploitation, or misappropriation of property. An interview with a business office staff member confirmed that the state Nurse Aide registry was not checked for these two employees before their start dates, and both had been working in the facility since their respective hire dates. This oversight had the potential to affect all residents, as the facility census was 33 at the time of the report. The failure to conduct these checks is a significant lapse in ensuring the safety and well-being of the residents, as it could allow individuals with a history of misconduct to be employed in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wakefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wayne Countryview Care And Rehabilitation | 7.1 mi | ★★★★★ | 8 | 0 |
| Heritage Of Emerson | 7.6 mi | ★★★★★ | 0 | 0 |
| Hillcrest Care Center | 15.3 mi | — | 0 | 0 |
| Wisner Care Center | 19.2 mi | ★★★★★ | 0 | 0 |
| Colonial Haven | 23.6 mi | ★★★★★ | 0 | 0 |
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