Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Medford Multicare Center For Living during CMS and state inspections, most recent first.
A resident with a history of cognitive impairment and a rib fracture alleged being punched by nursing staff. Although some staff interviews and a physical assessment were conducted, the facility did not document interviews with the overnight staff who were present during the alleged incident, as required by policy. The investigation was deemed incomplete due to this lack of documentation.
A CNA was observed on video surveillance roughly handling a cognitively impaired resident in a wheelchair by pulling them back and forth in a shaking motion. The resident, who had significant cognitive decline and multiple medical conditions, was identified as at risk for abuse in their care plan. The incident was not witnessed or reported at the time, but facility review later determined there was reasonable cause to believe abuse occurred.
A resident admitted with COVID-19 and requiring Droplet and Contact Precautions did not have a care plan developed, despite facility policy requiring care planning upon admission. The resident's room had precautionary measures in place, but the formal care plan was missing, as confirmed by staff interviews.
A resident with a PICC line for IV antibiotics was not properly monitored, as the facility failed to document assessments or measure the external catheter length. Despite physician orders for regular flushing and antibiotic administration, records showed no evidence of monitoring from early to late February. Staff interviews revealed gaps in protocol adherence and policy coverage regarding PICC line care.
A resident with severe cognitive impairment and multiple diagnoses, including heart failure, was receiving oxygen therapy without a physician's order. The resident had been on oxygen therapy since returning from the hospital, but facility staff, including an LPN and RN Manager, were unaware of the missing order. The oversight was discovered during a survey, and the physician confirmed the requirement for an order.
A resident with severe cognitive impairment and multiple diagnoses was receiving oxygen therapy without a physician's order or evaluation. Despite recommendations from a pulmonologist, the facility failed to document a care plan or obtain the necessary physician's order for the therapy. Observations confirmed the ongoing administration of oxygen, and interviews revealed a lack of awareness among staff about the missing documentation.
A facility failed to maintain an effective infection control program, as evidenced by two incidents involving residents with infectious conditions. A CNA exited a resident's room with Clostridium difficile without PPE, and a Respiratory Therapist changed a tracheostomy cannula for a resident with MDRO Pneumonia without a mask or face shield. Both incidents reflect a lack of adherence to infection control protocols.
A facility did not promptly report allegations of sexual abuse involving a resident with intact cognition. The resident reported being abused by a CNA to an LPN, who did not inform the administration. Despite further reports to another CNA and an RN, no immediate action was taken. The accused CNA continued to have access to the resident, posing an Immediate Jeopardy risk. The facility's policy required immediate reporting to the Administrator, DON, or designee, and to the New York State Department of Health within two hours. Interviews revealed discrepancies in reporting and handling the allegations, with staff citing the resident's past behavior as a reason for not taking the report seriously. The DON and Administrator were not informed until later, indicating a communication breakdown.
An allegation of sexual abuse by a CNA was reported by a resident, but there was no documented evidence of an immediate investigation. The CNA continued to work on the same unit as the resident, indicating a lack of prompt response. The facility's policy required immediate reporting and investigation, but key staff, including an RN, did not follow these protocols.
The facility failed to ensure accurate drug records and control drug counts across three nursing units. Discrepancies were found in the documentation and physical count of controlled medications for two residents, with licensed nurses admitting to oversights and lack of proper training.
The facility failed to ensure a resident's dignity and privacy by not covering the resident's urinary bag with a privacy bag, despite facility policies and care plan interventions. Staff acknowledged the oversight, and the Director of Nursing Services confirmed the requirement for a privacy bag when the urinary bag is in full view.
The facility failed to ensure that the interdisciplinary team determined the clinical appropriateness of self-administration of medications for a resident. The resident was observed with multiple inhalers in their room without a documented assessment or physician's order, despite facility policy requiring such measures.
The facility failed to ensure that comprehensive care plans were reviewed and revised for three residents, as required by policy. This deficiency was identified for residents with various diagnoses, including Diabetes Mellitus, Parkinson's Disease, and Chronic Obstructive Pulmonary Disease. Interviews with staff revealed inconsistencies in the responsibility for updating care plans, contributing to the deficiency.
The facility failed to ensure a safe environment for a resident at risk for falls by not consistently using Dycem non-slip mats under high floor mats as specified in the care plan. This led to multiple incidents where the resident was found on the floor or in precarious positions.
The facility failed to ensure proper labeling of tube feeding bottles for a resident and allowed another resident to lie flat during tube feeding, contrary to policy, leading to deficiencies in care.
The facility did not follow the dialysis center's recommendation to hold a resident's blood pressure medications before dialysis treatments and failed to notify the resident's physician. This resulted in the resident receiving blood pressure medications on two occasions prior to dialysis treatments, contrary to the dialysis center's instructions.
The facility failed to ensure timely insulin administration for two residents due to staffing issues. One resident received their insulin nearly two hours late, and another had their blood sugar checked and insulin administered after breakfast instead of before, as ordered by the physician. The delays were attributed to the late arrival of a second nurse, leaving one nurse responsible for the entire unit's medication administration.
The facility failed to provide adequate privacy curtains in a semi-private room, resulting in one resident feeling uncomfortable due to their roommate's behavior. The privacy curtain was too short, allowing one resident to see the other, and staff were either unaware of the issue or did not address it in the residents' care plans.
Failure to Document Thorough Investigation of Abuse Allegation
Penalty
Summary
The facility failed to ensure that all incidents, including allegations of abuse, were thoroughly investigated as required by their Abuse Prevention Program policy. On the morning of 4/14/2025, a resident with a history of fractured rib, COPD, and chronic kidney disease, and a moderate cognitive impairment, reported being punched in the ribs by nursing staff. The resident's care plan included monitoring for pain and complications related to their rib fracture. Documentation showed that a full body assessment was completed with no signs of injury, and the resident's next of kin noted similar past allegations at other facilities. The investigation summary concluded that abuse was not substantiated, based on interviews with some employees, a physical assessment, the resident recanting their statement, and a pattern of behavior confirmed by the next of kin. However, there was no documented evidence that the overnight staff, who would have been present during the alleged incident, were interviewed as part of the investigation. The facility's policy required statements from all relevant staff, but the investigation report lacked documentation of interviews with the overnight shift. Interviews with facility staff, including the DON and Administrator, confirmed that while verbal interviews with the night shift were reportedly conducted, they were not documented or included in the investigation file. The lack of documentation of these interviews meant the facility did not meet the requirement for a thorough investigation of the abuse allegation, as outlined in their own policy and regulatory standards.
Physical Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed on facility video surveillance using both hands to hold a resident's shoulders while the resident was seated in a wheelchair, pulling the resident back and forth in a shaking motion. The incident occurred when no other staff or residents were present. The facility's policy defines physical abuse as hitting, slapping, punching, and kicking. The resident involved had a history of neurocognitive disorder with Lewy bodies, chronic obstructive pulmonary disease, and Parkinson's Disease, and was unable to be assessed for mental status due to cognitive decline. The resident's care plan identified them as at risk for abuse due to cognitive impairment and inability to understand their surroundings. The facility's investigation determined there was reasonable cause to believe that abuse, neglect, or mistreatment occurred, noting that the event was unwitnessed and not reported at the time. The CNA stated that the resident was attempting to enter another room and that they repositioned the resident by holding their shoulders, denying any shaking motion. The administrator, upon reviewing the video, concluded that the CNA's actions constituted abuse based on the manner in which the resident was handled.
Failure to Develop Care Plan for COVID-19 Precautions
Penalty
Summary
The facility failed to ensure that a Baseline Care Plan was developed and implemented for a resident who was admitted with a positive COVID-19 infection and required Droplet and Contact Precautions. The resident, who had a history of Alzheimer's Disease and Rhabdomyolysis, was admitted with a physician's order for these precautions for ten days. However, there was no care plan documented in the resident's electronic medical record to address these precautions, which is a deviation from the facility's policy that mandates care planning upon admission. Observations and interviews revealed that the necessary precautions were physically in place, such as a sign and PPE cart outside the resident's room, but the formal care plan was missing. The Registered Nurse Clinical Care Coordinator and the Infection Preventionist both acknowledged the oversight, indicating that the care plan should have been initiated upon admission. The Director of Nursing Services confirmed that the admission nurse should have created the care plan, highlighting a lapse in the facility's adherence to its own care planning procedures.
Failure to Monitor and Document PICC Line Care
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for Resident #242, who was admitted with a Peripheral Inserted Central Catheter (PICC) in their right arm. The facility did not document monitoring of the PICC site or measure the length of the external catheter, which is essential to prevent complications such as catheter migration. The facility's policy on PICC lines, last reviewed in June 2024, required assessment of the insertion site for inflammation, tenderness, or drainage, but did not include guidance for measuring the external catheter. Despite physician orders to flush the PICC with Normal Saline every shift and administer Cefepime intravenously, there was no evidence in the Medication Administration Record or Treatment Administration Record that the PICC was assessed or measured from February 1 to February 24, 2025. Interviews with facility staff revealed a lack of clarity and adherence to protocols regarding PICC line care. The Registered Nurse Clinical Care Coordinator acknowledged the absence of an order to measure the external catheter and the need for daily assessments. The Registered Nurse Educator stated that the order should include measuring the external catheter length during dressing changes. The Director of Nursing confirmed that the facility policy did not address measuring the external catheter length, and staff should have documented their findings each shift. This oversight in monitoring and documentation led to the deficiency identified during the recertification survey.
Resident Received Oxygen Therapy Without Physician's Order
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and the comprehensive person-centered care plan for a resident who was receiving oxygen therapy without a physician's order. The resident, who had diagnoses including cerebral infarction, heart failure, and diabetes mellitus, was observed receiving oxygen therapy at a flow rate of 2 liters per minute via nasal cannula on multiple occasions. Despite the resident's need for oxygen therapy due to shortness of breath and hypoxia, there was no documented physician's order for the therapy or for monitoring the resident's oxygen saturation levels. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse Manager, and the Director of Nursing Services, revealed that they were unaware of the lack of a physician's order for the oxygen therapy. The resident had been receiving oxygen therapy since returning from the hospital in October 2024, but the oversight was not identified until the survey. The physician confirmed that oxygen therapy requires a physician's order and was unaware that the order was missing until informed by the facility.
Oxygen Therapy Administered Without Physician's Order
Penalty
Summary
The facility failed to ensure that a physician reviewed and documented the care plan for a resident receiving oxygen therapy. Resident #32, who had diagnoses including cerebral infarction, heart failure, and diabetes mellitus, was receiving oxygen therapy without a physician's evaluation or order. The resident's Minimum Data Set assessment indicated severely impaired cognition and documented the use of oxygen therapy. However, there was no care plan developed for this therapy, and no physician's order or progress note was found in the medical record to justify the administration of oxygen. Observations during the survey confirmed that the resident was receiving oxygen therapy at a flow rate of 2 liters per minute via nasal cannula. Interviews with the Registered Nurse Manager and the Director of Nursing Services revealed a lack of awareness regarding the absence of a physician's order for the oxygen therapy. The attending physician also confirmed that they were unaware of the missing order and recommendations from the pulmonologist, which included monitoring oxygen saturation levels and titrating oxygen as needed. This oversight led to the resident receiving oxygen therapy without the necessary physician's order and documentation.
Infection Control Breaches in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving residents with infectious conditions. Resident #521, who had a Clostridium difficile infection, was under Contact Precautions. However, on 2/25/2025, a Certified Nursing Assistant was observed exiting the resident's room without wearing any Personal Protective Equipment (PPE) such as a gown or gloves, despite a sign indicating the need for such precautions. The CNA was misinformed that the resident was no longer on Contact Precautions, leading to a breach in protocol. In another incident, Resident #147, who was ventilator-dependent and had a Multidrug-Resistant Organism (MDRO) Pneumonia, was also under Contact Precautions. On 2/27/2025, a Respiratory Therapist was observed changing the resident's tracheostomy inner cannula without wearing a mask or face shield, despite the potential for exposure to aerosolized particles. The therapist believed that a mask was not required due to the closed tracheostomy system, which was contrary to the guidelines for handling MDRO infections. Both incidents highlight a lack of adherence to established infection control protocols, as confirmed by interviews with the facility's Infection Preventionist, Director of Nursing Services, and Medical Director. The failure to follow proper PPE guidelines during these procedures increased the risk of transmission of infectious agents within the facility.
Failure to Report Allegations of Sexual Abuse Promptly
Penalty
Summary
During a Recertification Survey conducted between 4/17/2024 and 4/26/2024, it was found that a facility failed to promptly report allegations of sexual abuse involving Resident #26 to the Administrator or other officials. Resident #26, with intact cognition, reported being sexually abused by Certified Nursing Assistant #1 on 3/30/2024 to Licensed Practical Nurse #1, who did not report the allegations to the facility's administration. Despite subsequent reports of the same allegation by Resident #26 to Certified Nursing Assistant #3 and Registered Nurse #1, the facility did not take immediate action to address the situation. Certified Nursing Assistant #1 continued to have access to Resident #26 until 4/18/2024, posing an Immediate Jeopardy risk to the resident and other residents on the same unit. The facility's policy required immediate reporting of suspected abuse, neglect, or mistreatment to the Administrator, Director of Nursing Services, or designee, and to the New York State Department of Health within two hours of the allegation being made. Resident #26, who had a history of mental health diagnoses including Major Depressive Disorder, Bipolar Disorder, and Anxiety Disorder, reported the abuse, but the facility failed to follow its own reporting procedures. Despite a Comprehensive Care Plan being initiated after the surveyor brought the allegation to light, there was a lack of documented evidence in the Grievance Reports and Accident and Incident Reports regarding the sexual abuse allegation made by Resident #26. Interviews with staff members revealed discrepancies in reporting and handling the allegations. Certified Nursing Assistant #1 denied the allegations and continued to provide care to Resident #26 even after being accused of sexual abuse. Registered Nurse #1 failed to report the allegation to the administration and did not initiate an investigation, citing the resident's past accusatory behavior as a reason for not taking the allegation seriously. The Director of Nursing Services and the Administrator were not made aware of the allegations until later dates, indicating a breakdown in communication and reporting within the facility.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and mistreatment were thoroughly investigated, as evidenced by the case of Resident #26 during a Recertification Survey. Resident #26 reported on 3/30/2024 that they were sexually abused by Certified Nursing Assistant #1, but there was no documented evidence of any immediate action taken by the staff to initiate an investigation into the allegation. Despite the serious nature of the allegation, Certified Nursing Assistant #1 continued to be assigned to work on the same unit as Resident #26, indicating a lack of prompt response and protection for the resident. The facility's Investigation Policy and Procedure clearly outlined the steps to be taken in cases of alleged abuse, emphasizing the need for immediate reporting, thorough investigation, and removal of any staff suspected of abuse pending investigation results. However, in this case, there was a significant delay in responding to the allegation, with key staff members failing to follow the established protocols. Registered Nurse #1, who was informed of the allegation, did not initiate an investigation or report the incident to the administration, despite being responsible for such actions as per the facility's policy.
Controlled Drug Count Discrepancies
Penalty
Summary
The facility did not ensure that drug records were in order and accounted for all controlled drugs across three nursing units (Unit 1C, Unit 3C, and Unit 3B). Specifically, on Unit 1C, the daily control drug count sheet was not signed by two licensed nurses to reflect a physical count of the available controlled medications. Additionally, the daily control drug count sheet was not reconciled to reflect the available controlled medications in the medication blister pack for Resident #130, who had diagnoses including Cerebral Palsy, Chronic Pain Syndrome, and Aphasia. A manual count revealed discrepancies in the number of Oxycodone tablets documented versus the actual count in the blister pack. Licensed Practical Nurse #5 admitted to an oversight in signing the drug control sheet and inaccurately recording the count in the record. On Unit 3C, the daily control drug count sheet was also not signed by two licensed nurses, and the Controlled Drug Record form was not reconciled to reflect the available controlled medications in the medication blister pack for Resident #170, who had diagnoses including Dementia with Anxiety, Major Depressive Disorder, and Altered Mental Status. A manual count of Resident #170's Xanax tablets revealed discrepancies between the blister pack count and the daily control drug count sheet. Licensed Practical Nurse #9 and Licensed Practical Nurse #6 admitted to oversights in initialing the daily control drug count sheet and ensuring accurate documentation. On Unit 3B, the daily control drug count sheet was not signed by two licensed nurses at the beginning of the shift. Licensed Practical Nurse #10 admitted to not signing the unit's daily control drug count sheet at the beginning of their shift, stating they were never trained on the proper procedure. The Inservice Coordinator/Staff Educator confirmed that licensed nurses should have been trained to sign off on the unit's daily control drug count sheet at the beginning of their shift. The Director of Nursing Services emphasized the importance of both outgoing and incoming nurses conducting a count of all narcotic medications together and signing the daily control drug count sheet.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility did not ensure that each resident is treated with respect and dignity and cared for in a manner that promotes or enhances the resident's quality of life. Specifically, on two separate occasions, Resident #92 was observed in bed from the hallway with their urinary bag attached to the bed frame without a privacy bag, and the bag was observed to contain urine. This observation was made despite the facility's policy and procedure on Resident Privacy, which aims to ensure that all residents' right to privacy is respected and maintained in all aspects of care delivery. The resident's Comprehensive Care Plan also included an intervention to position the catheter bag and tubing away from the entrance room door, which was not followed in this case. Certified Nursing Assistant #9, who was assigned to Resident #92, acknowledged that they knew the resident's Foley bag did not have a privacy bag and admitted that they should have asked the Registered Nurse in charge for one. Registered Nurse #5 confirmed that the Foley drainage bag should have been covered with a privacy bag. The Director of Nursing Services stated that while the Foley drainage bag did not need a privacy bag during care, it should have been covered afterward, especially if it was in full view from the hallway. The facility's failure to adhere to its own policies and procedures resulted in a deficiency in maintaining the resident's dignity and privacy.
Failure to Ensure Clinical Appropriateness for Self-Administration of Medications
Penalty
Summary
The facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This deficiency was identified for one resident who was observed with multiple inhalers on top of their room dresser. There was no documented assessment by the interdisciplinary team to determine if the resident could safely self-administer and store these medications in their room. The facility's policy requires a physician's order and a care plan for residents to self-administer medications, but this was not followed in this case. The resident had a history of Chronic Obstructive Pulmonary Disease, Hypertension, and Depression, and their cognitive status had declined from intact to moderately impaired over time. During observations, the resident stated that they used the medications by themselves, and staff interviews revealed that there was no physician's order for self-administration of the inhalers. The Licensed Practical Nurse and Registered Nurse Manager both confirmed that a physician's order and care plan are necessary for self-administration, but they were unaware of who had left the inhalers in the resident's room. The Primary Care Physician and Nurse Practitioner also indicated that an assessment of the resident's ability to self-administer medications should be conducted, but there was no evidence that this had been done for the resident in question.
Failure to Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility did not ensure that person-centered comprehensive care plans were reviewed and revised to address each resident's needs. This deficiency was identified for three residents: one reviewed for rehabilitation and restorative services, one for respiratory care, and one for unnecessary medications. Specifically, there was no documented evidence that the comprehensive care plans for these residents were reviewed and revised by the interdisciplinary team after each comprehensive and quarterly review assessment, as required by the facility's policy and procedure. Resident #114, who was admitted with diagnoses including Diabetes Mellitus with diabetic neuropathy and generalized Osteoarthritis, had a comprehensive care plan for limited physical mobility that was not reviewed or revised in accordance with the Minimum Data Set (MDS) assessment schedule. Similarly, Resident #227, diagnosed with Parkinson's Disease, Dementia, and Heart Failure, had a respiratory care plan that lacked documented evidence of review and revision. Resident #186, with diagnoses of Chronic Obstructive Pulmonary Disease, Hypertension, and Depression, also had care plans for respiratory and anticoagulant therapy that were not updated as required. Interviews with facility staff, including Licensed Practical Nurses, Registered Nurses, the Director of the Minimum Data Set, and the Director of Nursing Services, revealed that the responsibility for initiating, maintaining, and updating care plans was not consistently followed. The staff acknowledged that care plans should be reviewed and updated quarterly, annually, with significant changes, and on an as-needed basis, but this was not consistently documented or executed. The facility's policy did not explicitly state that comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, contributing to the deficiency.
Failure to Ensure Safe Environment for Resident at Risk for Falls
Penalty
Summary
The facility did not ensure that Resident #226's environment was free from accident hazards and that the resident received adequate supervision and assistance devices to prevent accidents. Resident #226, who had a history of falls and was assessed as at risk for falls, had a comprehensive care plan that included the use of high floor mats with Dycem non-slip mats underneath to prevent slipping. However, during multiple observations, the Dycem non-slip mats were not in place under the high floor mats as required by the care plan. Resident #226 had several documented incidents of being found on the floor or in precarious positions between the bed and the high floor mats. These incidents occurred despite the care plan's intervention to use Dycem mats to prevent the high floor mats from slipping. Staff interviews revealed that the Dycem mats were not consistently used, and non-slip rug pads were sometimes used instead, which was not in accordance with the care plan. The Director of Nursing Services confirmed that it was unacceptable to use non-slip rug pads in place of Dycem mats and that the Dycem mats should always be in place and checked by Certified Nursing Assistants. The failure to consistently use the Dycem mats as specified in the care plan led to the deficiency in providing a safe environment for Resident #226.
Deficiencies in Enteral Feeding Care
Penalty
Summary
The facility did not ensure that residents who are fed by enteral means received appropriate treatment, care, and services to prevent complications of enteral feeding. Specifically, Resident #148's tube feeding bottles were not labeled with the nurse's initials, date, and time the feeding was initiated. This was observed on two separate occasions, and the nursing staff confirmed that the bottles should have been labeled to monitor the feeding accurately. The Director of Nursing Services acknowledged that the nursing staff should have labeled the tube feeding bottles according to the facility's policy. Additionally, Resident #69 was observed lying flat on their back while receiving tube feeding, which is against the facility's policy that requires the head of the bed to be elevated at 30 to 45 degrees during feedings to prevent aspiration. Certified Nursing Assistant #7 provided care to the resident without pausing the tube feeding, and Certified Nursing Assistant #8, who was assisting, did not realize the tube feeding was running. Both nursing assistants and the Licensed Practical Nurse involved acknowledged that the resident should not have been lying flat during the tube feeding. The Director of Nursing Services and Medical Doctor #2 confirmed that the resident's head of the bed should have been elevated to avoid the risk of aspiration. The facility's failure to adhere to its policies for labeling tube feeding bottles and ensuring proper positioning during feedings led to deficiencies in the care provided to Residents #148 and #69.
Failure to Follow Dialysis Center Recommendations
Penalty
Summary
The facility did not ensure that residents who require dialysis receive services consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, the dialysis center recommended holding a resident's blood pressure medications before dialysis treatments. However, the facility staff did not follow these recommendations and failed to notify the resident's physician. This deficiency was identified for one resident who was reviewed for dialysis care. The resident, who had diagnoses including End Stage Renal Disease (ESRD) and Hypertension, received dialysis treatment at an offsite kidney center. The dialysis center staff instructed the facility to hold the resident's blood pressure medications before dialysis treatments, but these instructions were not communicated to the resident's physician. As a result, the blood pressure medications were administered to the resident on two occasions prior to dialysis treatments, contrary to the dialysis center's recommendations. Interviews with the Director of Nursing Services and the Physician Assistant confirmed that the facility staff did not follow the dialysis center's instructions or notify the physician, leading to the deficiency.
Significant Medication Errors Due to Staffing Issues
Penalty
Summary
The facility did not ensure that residents were free from significant medication errors, as identified during a recertification survey. Specifically, Resident #79 did not receive their physician-ordered insulin injection on time. The insulin was scheduled to be administered at 9:00 AM but was actually given at 10:58 AM, nearly two hours late. This resident had a diagnosis of Type II Diabetes Mellitus and Hypertension, and their care plan included monitoring and reporting signs of hyperglycemia. The delay in insulin administration was attributed to staffing issues, as the second nurse did not arrive on time, leaving one nurse responsible for the entire unit's medication administration and blood sugar checks. Similarly, Resident #143, who also had a diagnosis of Diabetes Mellitus and Hypertension, did not have their blood sugar checked via fingerstick before meals as ordered by the physician. Consequently, the insulin was administered after breakfast at 10:18 AM instead of before the meal. The resident's care plan required strict monitoring of blood sugar levels and timely administration of insulin. The delay was again due to staffing issues, with only one nurse available to handle the medication administration for the entire unit until the second nurse arrived late. Interviews with the nursing staff and the Director of Nursing Services revealed that the delays were due to the late arrival of the second nurse, which left the first nurse overwhelmed with responsibilities. The Director of Nursing Services emphasized the importance of following physician orders and ensuring timely blood sugar checks and insulin administration. The physician also highlighted the potential risks of not adhering to the prescribed schedule for insulin administration, stressing the importance of strict monitoring for diabetic residents.
Inadequate Privacy Curtains in Semi-Private Room
Penalty
Summary
The facility did not ensure that each resident in a semi-private room had ceiling-suspended curtains that extended around the bed to provide total visual privacy. This deficiency was identified for two residents who shared a semi-private room. The privacy curtain separating the two residents was not long enough to allow full visual privacy, resulting in one resident being able to see the other through a gap between the bottom of the curtain and the floor. This issue was observed during the survey, and interviews with the residents and staff confirmed the inadequacy of the privacy curtain. One resident, who had a history of Cerebral Vascular Accident, Congestive Heart Failure, and Hypertension, reported feeling uncomfortable and grossed out by their roommate's behavior of touching themselves. Despite reporting this concern to staff members, there was no documented evidence in the resident's Comprehensive Care Plan addressing the issue. The other resident, who had diagnoses including Respiratory Failure, Aphasia, and Encephalopathy, also had no documented evidence in their Comprehensive Care Plan regarding their behavior of touching their genitals. Interviews with various staff members, including Certified Nursing Assistants, Licensed Practical Nurses, the Social Worker, the unit manager, and the Director of Environmental Services, revealed that the staff was either unaware of the privacy curtain issue or the discomfort it caused the resident. The Director of Nursing Services acknowledged that the privacy curtain should ensure full privacy for each resident and that staff should be aware of and address residents' privacy needs during care. The facility's policy on privacy curtains, effective April 2024, stated that the curtains should cover the entire length of the resident's bed area to provide full privacy, which was not adhered to in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Medford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Island Nursing And Rehab Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Brookhaven Health Care Facility, Llc | 3.2 mi | ★★★★★ | 3 | 0 |
| Swan Lake Nursing & Rehabilitation | 3.9 mi | ★★★★★ | 5 | 1 |
| Bellhaven Center For Rehab And Nursing Care | 4.6 mi | ★★★★★ | 3 | 1 |
| Quantum Rehabilitation And Nursing Llc | 4.6 mi | ★★★★★ | 2 | 0 |
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