Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Brookline Nursing And Rehab during CMS and state inspections, most recent first.
Kitchen sanitation and dishwasher temperature control failures: Surveyors observed peeling shelves, dust, cobwebs, stains, peeling paint, and an open wall area exposing joists and insulation in the main kitchen and dry goods rooms. They also observed the hot water sanitizing dishwasher repeatedly failing to reach the 155°F minimum listed on the manufacturer placard, and the temperature log showed multiple wash cycles documented below that level.
Improper Storage of Foley Catheter Equipment: A resident with urinary retention had a Foley catheter with orders for a leg bag during the day and a drainage bag at night. Surveyors observed the unused drainage bag stored in an open plastic bag tied to a toilet assist bar, with uncapped tubing and a urine graduate in the same bag. The resident’s roommate used the bathroom independently, and the LPN, NHA, and DON confirmed the facility had no policy, procedure, or competency materials for proper storage of catheter equipment during non-use.
Failure to Monitor and Justify Antipsychotic Use: A resident with major depressive disorder, PTSD, suicidal attempt, CKD, and vascular dementia was ordered Abilify along with antidepressants, but the record did not show identification of PTSD triggers, tracking of target behaviors, non-medicinal interventions, or monitoring for antipsychotic side effects. The care plan also lacked evidence of a plan to address distressing behaviors or symptoms such as hallucinations, aggression, self-harm, or isolation.
Facility staff failed to provide written transfer notices to resident representatives for three residents and failed to provide written bed-hold notices for two residents who were sent to the hospital. Records showed one resident transferred after a change in condition and bilateral kidney stones, another left via EMS for a mental health crisis, and a third transferred for a surgical procedure; in each case, the resident signed the forms, but there was no documentation that the responsible party or designated representative received written copies.
A resident’s admission MDS was coded incorrectly to show that he did not have PTSD, even though the clinical record and an active physician order documented PTSD. The psychiatry note identified the resident as a military veteran and described PTSD symptoms, and the DON confirmed staff failed to include the diagnosis on the MDS.
Failure to Develop PTSD-Related Care Plan: A resident with PTSD, recent bereavement, and a suicide attempt was found with a cord around his neck and displayed paranoid, scattered thoughts and distressing statements. The record did not show a person-centered, trauma-informed care plan, identification of triggers, tracking of target behaviors, or non-medicinal interventions for symptoms such as self-harm, aggression, hallucinations, or isolation, and the MDS was coded incorrectly for PTSD.
A dependent resident did not receive consistent ADL assistance with bathing and nail care. The resident’s care plan identified him as needing staff help with showering, bathing, and personal hygiene, but his daughter reported his hair and fingernails were long and she was upset by his appearance. Records showed inconsistent bathing documentation, and when observed, his fingernails were long, uneven, and broken; an aide confirmed they did not appear to have been trimmed with his shower.
Respiratory care for a resident with acute and chronic respiratory failure with hypercapnia and OSA was not managed consistent with policy and professional standards. The resident had an order for NIV at night and with naps, but the order did not include device settings, and the care plan did not address settings, cleaning, resident assessment, or monitoring for complications. In addition, suction units in two dining rooms were observed with expired tubing and a yankauer suction tip kept with the equipment.
Pain management was not provided with clear physician parameters for a resident with shoulder pain and myalgia. The resident had orders for Tramadol, Acetaminophen, and Morphine for pain, but the Acetaminophen and Morphine orders did not specify pain parameters for administration. The issue was reviewed with the NHA and DON.
Failure to ensure a resident received pneumococcal immunization unless refused or contraindicated. The resident had previously refused Pneumovax 23, but the record showed no evidence the vaccine was offered again for years afterward. A later consent form showed the resident understood the risks and benefits of PCV20 and requested it, yet there was no evidence the vaccine was administered. The DON could not provide evidence of post-refusal education during the survey.
The facility failed to follow its abuse and neglect reporting policy by not thoroughly investigating or reporting two separate allegations involving residents. One resident reported that a female staff member was rough, made a threatening remark when asked for positioning assistance, and left her fearful of using the call bell; days later, the resident was found with a large right flank/hip hematoma that required diagnostic testing and an ED visit, yet the facility did not investigate the cause to rule out abuse or report it to required agencies. In another case, a resident who was frequently incontinent and dependent for hygiene was reported by a granddaughter to have received no care all day and was later found soaked through sheets and bed pads; the facility did not treat this as a neglect allegation, did not obtain staff statements, and did not report the concern to appropriate authorities.
The facility failed to develop and implement person-centered care plans for residents diagnosed with dementia. A resident admitted in 2018 and diagnosed in 2022, another admitted in 2022, and a third admitted in 2023 all lacked individualized care plans despite assessments indicating the need. These deficiencies were discussed with the facility's administration.
The facility's main kitchen had several deficiencies, including a large hole in the dishwashing area wall, dust build-up on the air handler, and expired items in the first aid kit and pantry. A drink used for colonoscopy preps was improperly stored with commercial cleaner. Additionally, food temperature logs were incomplete for two dates. These issues were identified during a tour with the Dietary Manager and discussed with the Nursing Home Administrator and DON.
The facility did not ensure that three nurse aides received the mandated 12 hours of annual in-service training. This deficiency was confirmed through a review of education records and interviews with the Nursing Home Administrator and DON, who acknowledged the absence of documentation for the required training.
The facility failed to accommodate the needs of two residents by not responding timely to call bell activations. One resident reported delays of up to an hour, and facility records confirmed multiple instances of prolonged response times. The facility's call bell documentation was inadequate, and staff could not explain the delays.
The facility failed to maintain a clean and orderly environment on Unit 3, as observed by marred drywall behind the beds of two residents. These deficiencies were discussed with the Nursing Home Administrator and DON.
The facility failed to provide written notice of the bed hold policy to two residents or their representatives at the time of hospital transfer. This deficiency was confirmed during interviews with the Nursing Home Administrator and the DON.
A facility failed to provide appropriate treatment for a resident frequently incontinent of bladder. Despite being cognitively intact and requiring assistance for toileting, the facility did not assess the resident's incontinence type or develop a toileting program, as confirmed by the Nursing Home Administrator and DON.
A facility failed to store supplemental oxygen equipment properly for a resident with respiratory conditions. The nasal cannula was found in the back storage area of the resident's wheelchair, unprotected from contamination and in contact with footrests. This was confirmed by a registered nurse and reviewed with the Nursing Home Administrator and DON.
A facility failed to fully assess the risk of side rail entrapment for a resident. Although an assessment and consent were completed, the evaluation only covered zone six, omitting zones one, two, three, and four. This deficiency was confirmed in an interview with the Nursing Home Director and DON.
The facility failed to provide required written notifications to residents and/or their responsible parties for hospital transfers, affecting four residents. The notifications lacked essential information such as the reason for transfer, effective date, and appeal rights. These deficiencies were confirmed by the Nursing Home Administrator and DON.
The facility failed to follow its abuse policy and thoroughly investigate two incidents involving a resident. In both cases, the LPN who documented the events was not the witness, and there was no evidence that the actual witnesses were interviewed or that signed statements were obtained. The Administrator and DON acknowledged these findings.
The facility failed to follow physician orders for bowel protocol medication administration for two residents and did not provide adequate care plan details for a resident with a cardiac pacemaker, resulting in inadequate care.
The facility failed to provide the appropriate physician-ordered enteral nutrition for a resident with a feeding tube. Observations and staff interviews revealed that the pump settings allowed 520 ml of liquid nutrition to infuse over eight hours before initiating the water flush, which did not comply with the physician's order for water every six hours. The facility did not provide evidence that the resident received the prescribed 250 ml of water every six hours until after the surveyor's questioning.
The facility failed to maintain clear and consistent documentation of advance directives for two residents. One resident's POLST indicated full treatment, but a physician's order listed DNR. Another resident's POLST indicated DNI, but the physician's order did not reflect this. Both discrepancies were corrected during the survey.
The facility failed to implement fall prevention measures for a resident and did not secure the main entrance, posing potential accident hazards. A resident's chair alarm was incorrectly placed, and the main entrance was left unsecured without staff monitoring.
A facility failed to administer supplemental oxygen as prescribed for a resident. Despite a physician's order for three liters per minute, observations and staff interviews confirmed the resident was receiving only two liters per minute.
A resident exhibited multiple inappropriate behaviors and was prescribed Prozac on October 24, 2023. However, the medication was not added to the resident's regimen until a month later, despite being noted by nursing staff. The DON confirmed these findings.
The facility failed to maintain a medication error rate below five percent. An LPN improperly administered a Tolterodine Tartrate ER capsule by opening it and mixing it with applesauce, and did not ensure a resident rinsed their mouth after using a Trelegy Ellipta inhaler, leading to a medication error rate of 5.56 percent.
The facility failed to ensure safe and sanitary storage and handling of personal food products for a resident. Expired food items and outdated temperature monitoring logs were found in the resident's personal refrigerator, and additional expired items were observed on a subsequent inspection with the DON. The facility did not adhere to its policy on discarding perishable foods and those showing signs of potential foodborne danger.
Kitchen sanitation and dishwasher temperature control failures
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and failed to maintain kitchen equipment in a sanitary condition in the main kitchen. During an initial tour with the dietary manager, surveyors observed flaking and/or peeling shelves in a cupboard holding drink pitchers next to the food preparation sink, a large accumulation of black-colored dust around a white pipe entering the ceiling, dust on the wall behind refrigerators that held tray carts, a baseball-sized area of peeling paint on the ceiling above a food prep area, cobwebs and a large gap where the ceiling met the wall in two dry goods storage rooms, a black substance on the wall behind the dishwasher, dried stains on the wall under a stainless-steel table beside the dishwashing machine, and an open wall area exposing joists and insulation near pipes extending to a sink. Surveyors also observed the dishwasher in operation and found that the wash cycle temperature did not reach the minimum 155 degrees Fahrenheit listed on the manufacturer placard. On one observation, the maximum wash temperature reached 152 degrees Fahrenheit, and on another observation two days later, the maximum wash temperature reached 150 degrees Fahrenheit. Review of the February 2026 dishwasher temperature log showed multiple documented wash temperatures below 155 degrees Fahrenheit, including entries of 150 and 152 degrees on several breakfast, dinner, and supper cycles. The dietary manager confirmed the dishwasher was a hot water sanitizing dishwasher, and the findings were reviewed with the Nursing Home Administrator and the DON.
Improper Storage of Foley Catheter Equipment
Penalty
Summary
The facility failed to store indwelling urinary catheter equipment in a manner to prevent potential infection for one resident with urinary retention. The resident had active physician orders for a Foley catheter to be changed as needed for obstruction or dislodgement and every 30 days for routine care, along with orders to use a leg bag during the day and a drainage bag during sleep. During observation, the resident was in a wheelchair and stated that the Foley urine collection bag was underneath his clothing and secured to his leg. The larger urinary collection bag that was not in use was observed stored in an open plastic bag tied to the toilet assist bar. The tubing connected to the larger collection bag was not capped, exposing the tip to potential contamination, and the plastic bag also contained a urine graduate. Staff confirmed that the resident’s roommate ambulates independently and uses the bathroom for toileting. The Nursing Home Administrator and DON stated that the facility had no policy, procedure, or competency education materials addressing proper storage of indwelling urinary catheter equipment to prevent contamination from the environment during non-use.
Failure to Monitor and Justify Antipsychotic Use
Penalty
Summary
The facility failed to identify and monitor the medical symptoms that warranted the use of an antipsychotic medication and failed to monitor for potential adverse consequences of antipsychotic use for one resident. The resident had diagnoses including major depressive disorder, PTSD, suicidal attempt, CKD, and vascular dementia, and the psychological services note stated the resident had been in the hospital after a suicide attempt involving a call bell rope after losing his wife. Active physician orders included Abilify 5 mg at bedtime, later decreased to 2.5 mg at bedtime, along with Mirtazapine 15 mg at bedtime and Sertraline 150 mg daily. The clinical record did not show that the facility identified the traumatic event that precipitated the PTSD, identified triggers that could worsen symptoms, tracked distressing target behaviors that supported antipsychotic use, or established non-medicinal behavioral interventions to reduce or eliminate those behaviors. The record also did not provide evidence that the resident was monitored for physical side effects from the antipsychotic, and the care plans did not include a plan to address potential distressing behaviors or symptoms such as hallucinations, aggression, self-harm, or isolation.
Failure to Provide Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written notice of transfer to the resident representative for three residents and failed to provide written notice of the bed-hold policy for two residents who were hospitalized. For one resident, nursing documentation showed a change in condition, a call/message left for the responsible party and son, EMS arrival, and transfer to the hospital for bilateral kidney stones; the resident signed a Notice of Transfer or Discharge, but there was no evidence that the resident representative was notified in writing as soon as practicable. For another resident, documentation showed emergency medical services transport from the facility due to a mental health crisis. A Bed-Hold Notification form and a Notice of Transfer or Discharge were signed by the resident, but the responsible party signature line was blank and there was no documentation that either designated resident representative received a written copy. For a third resident, documentation showed transfer to the hospital for a surgical procedure and later return to the facility; the resident signed both the Bed-Hold Notification and Notice of Transfer or Discharge, but the responsible party signature line was blank and there was no documentation that either designated resident representative received written copies of the notices.
Incorrect MDS Coding for PTSD
Penalty
Summary
The facility failed to ensure that Resident 9’s assessment accurately reflected his status when staff incorrectly coded the admission MDS to indicate that he did not have PTSD. Clinical record review showed a psychiatry progress note documenting that Resident 9 was a military veteran and that his wife had died three weeks before the assessment, and the practitioner listed PTSD with thoughts, avoidance behaviors, negative changes in mood and cognition, and intrusive thoughts related to a traumatic event. An active physician’s order also admitted Resident 9 to skilled care for diagnoses that included PTSD. Review of the admission MDS dated [DATE] showed that the PTSD item was coded incorrectly as absent. The DON confirmed in interview that staff failed to code the admission MDS to include the resident’s PTSD diagnosis.
Failure to Develop PTSD-Related Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered, trauma-informed care plan to meet one resident’s mental and psychosocial needs. Clinical documentation showed the resident was found in bed with a cord around his neck and stated he did this to get staff’s attention. He then expressed paranoid and scattered thoughts, including beliefs that his daughter killed his wife, that others were involved in covering it up, and that he could wrap his hands around someone’s neck and “snap” it without anyone knowing. He was also described as very distraught and making additional statements about war, cheating, and family-related events. Psychiatry documentation identified the resident as a military veteran whose wife had died three weeks before the assessment, and the practitioner listed PTSD among the diagnoses. The resident was admitted to skilled care with PTSD, but the admission MDS incorrectly coded him as not having PTSD. The clinical record did not show that the facility identified the traumatic event related to his PTSD, identified triggers that could worsen symptoms, tracked distressing target behaviors, or established non-medicinal behavioral interventions. The care plans reviewed did not include a plan to address his distressing behaviors or symptoms such as hallucinations, aggression, self-harm, or isolation. The facility later initiated a care plan only after the surveyor questioned the lack of one, and the DON confirmed staff had failed to initiate a plan of care upon readmission to address PTSD, grief related to his wife’s death, and his suicide attempt.
Failure to Provide ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to ensure assistance with activities of daily living for a dependent resident. Resident 66’s care plan, developed on December 11, 2025, identified him as dependent on staff for showering/bathing and personal hygiene needs. During an interview, his daughter stated that she believed his fingernails were long and his hair was long, and she was upset by how he looked during her visit on February 12, 2026. Observation and record review showed that Resident 66’s hair was cut short on February 25, 2026, and he stated he was going to therapy to shave and that the barber had cut his hair that morning. However, his fingernails were observed to be long, uneven, and with the right ring fingernail broken. He stated he needed to cut his fingernails but did not have clippers. A nurse aide stated staff should trim a resident’s nails with each shower and confirmed it appeared Resident 66’s nails had not been trimmed with his shower. Documentation showed showers on January 7, 14, 21, and 28, 2026, a notation of not applicable on February 4, 2026, bed baths on February 11 and 15, 2026, and a shower on February 22, 2026, but the documentation also reflected bathing only on Wednesdays despite the plan indicating showers every Sunday.
Respiratory Care and Suction Supplies Not Properly Managed
Penalty
Summary
Respiratory care for non-invasive ventilation was not provided in accordance with professional standards of practice for one resident with acute and chronic respiratory failure with hypercapnia and obstructive sleep apnea. The resident had a physician order for NIV at night and with naps, with instruction to keep the machine upright and not lying flat to prevent air intake from being blocked. The facility policy for CPAP/BiPAP support stated that preparation for use included reviewing the physician order to determine oxygen concentration and flow and PEEP, and that mode and settings for the device should be documented in the resident's medical record. However, the physician order did not include device settings, and the resident's care plan only addressed NIV use per physician orders without additional details such as settings, cleaning, resident assessment, or monitoring for complications. Staff were documenting application of the device on the TAR, and an RN stated that the settings should be located in the physician orders. The facility also maintained respiratory-related equipment supplies in an unsafe and unsanitary manner in two dining rooms. In the restorative dining room, a suction unit was observed on a countertop with expired packaged items kept with it, including connection tubing and connective tubing. In the main dining room, a suction unit was also observed on a countertop with expired packaged items kept with it, including connective tubing and a yankauer suction tip. The DON was notified of the expired items, and the information regarding the resident and the equipment observations was reviewed with the NHA and DON.
Pain Medication Orders Lacked Administration Parameters
Penalty
Summary
Safe, appropriate pain management was not provided for Resident 3, whose clinical record listed pain in an unspecified shoulder and myalgia. The care plan identified pain related to the resident’s medical history and included pain medications per physician orders. Review of the current physician orders showed Tramadol 50 mg by mouth every 4 hours as needed for moderate to severe pain and also scheduled twice daily for moderate to severe pain. The record also included an order for Acetaminophen 325 mg, two tablets by mouth every 4 hours as needed for pain, and an order for Morphine Sulfate oral solution 20 mg/ml, 0.5 ml by mouth every 1 hour as needed for shortness of breath/pain. The Acetaminophen and Morphine orders did not specify pain parameters for administration. This information was reviewed with the NHA and DON.
Failure to Ensure Pneumococcal Vaccination Offer and Administration
Penalty
Summary
The facility failed to ensure that a resident received pneumococcal immunizations unless the vaccine was refused or clinically contraindicated. Review of the facility’s Pneumococcal Vaccine policy showed that all residents are to be offered pneumococcal vaccines, with education provided before administration and refusals documented in the medical record. Clinical record review for Resident 12 showed that he last refused a Pneumovax 23 vaccine on November 16, 2018, and there was no evidence in the record that the facility offered him a pneumococcal vaccine again in the more than seven years after that refusal. During the survey, the Director of Nursing was asked to provide evidence of education given to Resident 12 about the risks and benefits of pneumococcal vaccination after November 2018, but none was identified at that time. A Vaccination Consent Form dated September 12, 2025, later showed that Resident 12 acknowledged understanding the benefits and risks of a PCV20 (Prevnar 20) vaccination and requested that it be given, but there was no evidence that the facility administered the PCV20 immunization. The concern was reviewed again with the DON during a later interview.
Failure to Investigate and Report Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Investigation and Reporting policy by not thoroughly investigating and reporting allegations of abuse and neglect for two residents. The policy, last reviewed on November 20, 2025, required that all reports of abuse, neglect, exploitation, misappropriation of property, mistreatment, and injuries of unknown origin be promptly reported to specified local, state, and federal agencies and thoroughly investigated by facility management. Contrary to this policy, the facility did not treat certain resident and family reports as allegations of abuse or neglect and therefore did not initiate required investigations or notifications. For one resident (CR1), a concern/grievance report dated January 8, 2026 documented that the resident reported a female staff member entered her room the previous night, was grumpy, and stated, “you asked for it, now you got it” after the resident requested a wedge behind her back. The resident reported that a pad was placed on her spine, that she could not find the call bell, and that she was scared. A summary by the DON indicated that the DON and social services director met with the resident, who stated someone was being rough with her at night, did not place a wedge under her back, and that she was afraid to use the call bell in case the person returned. The resident could not identify the staff member because her eyes were closed. The DON reviewed staff and obtained written statements from two night-shift nurse aides, and those aides felt the resident was hallucinating. Subsequently, clinical notes documented a purplish area on the resident’s right flank/hip extending below the right abdominal fold, an ultrasound-confirmed hematoma in that area, and an emergency room visit for a large bruise/hematoma to the right abdomen and hip. The facility was unable to provide any information showing that it investigated the cause of the hematoma to rule out abuse. For another resident (CR2), who was assessed on the admission MDS as frequently incontinent of bowel and bladder and dependent on staff for personal and toileting hygiene, nursing documentation on November 10, 2025 recorded that the resident’s granddaughter informed the nurse that no nurse aide staff had been in the room all day to provide care. The documentation indicated that a nurse aide went into the room at approximately 2:10 PM and was refused entry by the granddaughter, and when the aide later returned to provide care, the resident was found soaked from incontinence through the sheets and bed pads. The Nursing Home Administrator stated that the facility did not identify the granddaughter’s report of no care all day as an allegation of neglect, did not obtain statements from staff who provided or attempted to provide care that day to rule out potential neglect, and did not report the allegation to the appropriate agencies. The DON and Administrator also stated that they did not more thoroughly investigate or report the events involving CR1 because they did not feel there was any allegation of abuse.
Failure to Implement Person-Centered Care Plans for Dementia
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for residents diagnosed with dementia, as evidenced by the cases of three residents. Resident 18 was admitted on July 13, 2018, and diagnosed with dementia on October 3, 2022. Despite the facility's assessment on February 9, 2025, indicating the need for a care plan, no person-centered care plan was developed for Resident 18's dementia and cognitive loss. Similarly, Resident 55, admitted on May 15, 2022, with a diagnosis of dementia, also lacked a person-centered care plan despite the facility's assessment indicating the necessity for one. Resident 61, admitted on May 27, 2023, with a dementia diagnosis added on May 31, 2023, was also found to be without a person-centered care plan addressing her dementia and cognitive loss. These deficiencies were identified through clinical record reviews and staff interviews, and were discussed with the Nursing Home Administrator and Director of Nursing on March 20, 2025. The facility's failure to implement these care plans is a violation of the specified nursing services and resident care plan regulations.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the main kitchen. During an initial tour of the kitchen, a large hole was observed in the wall of the dishwashing area, with two wall tiles fallen onto the ground. There was an extensive build-up of dust on the air handler appliance. The wall-mounted first aid kit contained burn spray and eye wash that were expired, and the pantry area held expired hand wipes. Additionally, a bottled drink used for colonoscopy preps was stored alongside commercial sanitizer/cleaner. A review of the food temperature logs for February 2025 revealed missing documentation for dinner food temperatures on two specific dates. These findings were discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training annually, as mandated by regulations. This deficiency was identified during a review of employee education records and staff interviews. Specifically, three nurse aides, referred to as Employees 1, 2, and 3, did not have documented evidence of completing the necessary training hours. The issue was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged the lack of documentation for the required training.
Failure to Timely Respond to Call Bells
Penalty
Summary
The facility failed to provide a reasonable accommodation of needs in response to call bell activations for two residents on Unit 2. Resident 57, who has a diagnosis of dementia but was assessed with no cognitive impairment, reported that staff do not respond to call bell activations in a timely manner, sometimes taking an hour or longer. This concern was corroborated by the Room Event Report, which documented multiple instances of call bell activations with elapsed times exceeding 20 minutes, with some instances extending over an hour. Resident 14, who shares a room with Resident 57, was noted to have cognitive decline and was unable to be interviewed due to confusion. The facility's documentation system for call bell activations was found to be inadequate, as it did not provide resident-specific data, only room-specific data. Interviews with the Nursing Home Administrator and Director of Nursing revealed that the facility could not explain the extended response times. Resident 57 also mentioned that he sometimes rings the call bell for Resident 14 due to the latter's confusion.
Inadequate Housekeeping and Maintenance on Unit 3
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on Unit 3, affecting two residents. Observations on March 18, 2025, revealed that the drywall was marred behind the head of the bed and the recliner of Resident 51, as well as behind the head of the bed of Resident 73. These findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 20, 2025.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents or their representatives at the time of transfer to a hospital, as required by regulations. This deficiency was identified for two residents who were transferred to the hospital following a change in their medical condition. Resident 11 was transferred on March 17, 2025, and there was no documentation that the facility provided the required written notice regarding the bed hold policy to the resident or their responsible party. Similarly, Resident 70 was transferred on March 5, 2025, and the facility also failed to document that the resident's representative received the written notice of the bed hold policy. These findings were confirmed during interviews with the Nursing Home Administrator and the Director of Nursing on March 21, 2025.
Failure to Develop Toileting Program for Incontinent Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to promote bladder continence for a resident identified as frequently incontinent of bladder. The facility's policy on urinary continence and incontinence assessment and management requires nursing staff and physicians to screen residents for urinary incontinence, document relevant details, and develop a toileting plan if necessary. However, the clinical record of the resident showed no documented evidence that the facility's physician or nursing staff assessed the resident to determine the type of urinary incontinence or developed an individualized toileting program or plan of care. The resident, who was assessed as cognitively intact with a BIMS score of 15, required extensive assistance from two staff members for toileting. Despite this, the facility did not attempt a urinary toileting program, as indicated in the Minimum Data Set Assessment. The Nursing Home Administrator and the Director of Nursing confirmed these findings, indicating a failure to adhere to the facility's policies and procedures for managing urinary incontinence.
Improper Storage of Supplemental Oxygen Equipment
Penalty
Summary
The facility failed to store supplemental oxygen equipment according to professional standards of practice for a resident with significant respiratory conditions. The resident had a medical history that included acute and chronic respiratory failure with hypercapnia, COPD, and pulmonary embolism. The physician's orders required supplemental oxygen at five liters per minute via nasal cannula to maintain a pulse oximeter reading greater than 90 percent. However, observations revealed that the nasal cannula was improperly stored in the back canvas storage area of the resident's wheelchair, alongside two footrests, exposing it to potential contamination. The deficiency was identified during observations on two consecutive days, where the nasal cannula was found unprotected from environmental contamination and contact with the footrests. This improper storage was confirmed by a registered nurse unit manager, who acknowledged that the wheelchair belonged to the resident. The findings were subsequently reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to adhere to proper respiratory care equipment storage protocols.
Incomplete Side Rail Entrapment Assessment
Penalty
Summary
The facility failed to adequately assess the risk of side rail entrapment for Resident 72, who was one of three residents reviewed for accident hazards. An observation of Resident 72's room revealed a left one-quarter side rail on the bed. Although the facility completed a side rail assessment, reviewed potential risks, and obtained consent on February 7, 2025, the entrapment evaluation was incomplete. The facility only assessed zone six, neglecting to evaluate zones one, two, three, and four, which are critical areas for potential entrapment. This oversight was confirmed during an interview with the Nursing Home Director and the Director of Nursing.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents and/or their responsible parties regarding hospital transfers, as required by regulations. This deficiency was identified for four out of five residents reviewed. Specifically, Resident 11 was transferred to the hospital on March 17, 2025, due to a change in condition, but there was no documentation of written notification to the resident or their responsible party. The notification should have included the reason for the transfer, the effective date, the location of the transfer, and information about the resident's right to appeal, among other details. Similarly, Resident 39 experienced multiple hospital transfers between December 2024 and January 2025, yet there was no evidence of written notification to the responsible party. Resident 48 was transferred from February 3 to 7, 2025, and Resident 70 from March 5 to 7, 2025, without the required written notifications. These findings were confirmed by the Nursing Home Administrator and the Director of Nursing during interviews conducted on March 21, 2025.
Failure to Investigate Abuse Incidents
Penalty
Summary
The facility failed to initiate their abuse policy and thoroughly investigate incidents to rule out the potential for abuse for Resident 64. The policy entitled Abuse Investigation and Reporting, last reviewed on November 17, 2023, requires that if an incident, suspected incident, or resident abuse is reported, the Administrator will assign the investigation to an appropriate individual. This individual is supposed to review the resident's medical record, interview the person reporting the incident, and interview any witnesses to the incident, obtaining written and signed statements. However, the facility did not follow these procedures for two incidents involving Resident 64. In the first incident, nursing documentation dated January 4, 2024, indicated that Resident 64 rubbed a female resident's buttocks two times and laughed when told to stop. Employee 3, an LPN, documented the event but was not the witness, and there was no evidence that the actual witness was interviewed or that a signed statement was obtained. In the second incident, nursing documentation dated February 23, 2024, indicated that Resident 64 was found holding a female resident's arm and kissing her, and later blocking her from leaving her bathroom. Again, Employee 3 documented the event but was not the witness, and there was no evidence of a thorough investigation. The Administrator and Director of Nursing acknowledged these findings during an interview on March 21, 2024.
Failure to Follow Bowel Protocol and Pacemaker Monitoring
Penalty
Summary
The facility failed to provide the highest practicable care regarding bowel protocol medication administration for two residents and the use of a cardiac pacemaker for another resident. For the first resident, the clinical record revealed a care plan addressing constipation with specific physician orders for Milk of Magnesia, Dulcolax suppository, and Fleet's Enema. Despite documented no bowel movements over several days, there was no indication that staff offered or the resident refused the prescribed PRN medications. Similarly, the second resident had physician orders for bowel management, but staff did not administer the PRN medications despite several days of no bowel movements, nor was there any documentation of refusal by the resident. These findings were confirmed in a meeting with the Nursing Home Administrator and Director of Nursing. For the third resident with a cardiac pacemaker, the clinical record indicated an active physician order for pacemaker checks per the cardiology schedule. However, the plan of care and physician orders lacked details on the type of pacemaker, the method of checks, and emergency procedures for utility outages. The resident had a dual chamber pacemaker for complete heart block, and the pacemaker monitoring machine was found functional in the resident's room. The Director of Nursing confirmed the continuous monitoring but was unaware of the communication method between the monitor and the cardiology office, and this information was not included in the resident's plan of care. The deficiencies highlight the facility's failure to adhere to physician orders and care plans for bowel management and pacemaker monitoring, resulting in inadequate care for the residents. The lack of documentation and follow-through on prescribed interventions and the absence of detailed care plans for critical medical devices were significant issues identified during the survey.
Failure to Adhere to Physician's Orders for Enteral Nutrition
Penalty
Summary
The facility failed to provide the appropriate physician-ordered enteral nutrition for a resident with a feeding tube. The resident had an active physician's order to receive Isosource 1.5 liquid nutrition at a rate of 65 ml per hour and 250 ml of water every six hours. However, observations and staff interviews revealed that the pump settings allowed 520 ml of liquid nutrition to infuse over eight hours before initiating the water flush, which did not comply with the physician's order for water every six hours. This discrepancy was confirmed by a licensed practical nurse who stated that the pump settings were typically cleared and reset at the beginning and end of her shift, approximately every eight hours, not every six hours as required by the physician's order. The clinical record review showed that staff documented providing 520 ml of feeding and 250 ml of water every shift from the beginning of the month until the surveyor's questioning. It was only after the surveyor's intervention that the physician's order was revised to align with the actual practice of infusing 390 ml of feeding and 250 ml of water every six hours. The facility did not provide evidence that the resident received the prescribed 250 ml of water every six hours until after the surveyor's questioning, indicating a failure to adhere to the physician's orders for enteral feeding and hydration.
Failure to Maintain Consistent Advance Directives
Penalty
Summary
The facility failed to establish clear and consistent resident wishes regarding advance directives for two residents. For Resident 32, the clinical record showed a POLST form signed by the responsible party indicating a wish for full treatment, including CPR. However, a physician's order dated the next day indicated a DNR status, with no documented evidence of a change in the resident's or responsible party's wishes. This discrepancy was only identified and corrected during the on-site survey. For Resident 26, the clinical record had an active physician's order for full code treatment without specific directions. A POLST signed by the resident's son and initialed by the physician indicated full code treatment but refused intubation (DNI). This DNI omission was identified during the surveyor's review and was corrected following the surveyor's questioning. Both cases highlight the facility's failure to maintain accurate and consistent documentation of residents' advance directives.
Failure to Implement Fall Prevention and Secure Main Entrance
Penalty
Summary
The facility failed to implement interventions to prevent falls and/or injuries for one resident and failed to prevent a potential accident hazard at the facility's main entrance. Specifically, Resident 57 had a physician's order for a sensor pad alarm to be applied to her chair and checked every shift for safety. However, observations on two separate occasions revealed that the alarm was placed on her wheelchair instead of her recliner, where she was seated. Concurrent interviews with Resident 57's family confirmed these observations, indicating a failure to follow the prescribed safety measures for the resident. Additionally, the facility's main entrance was found to be unsecured during the early morning hours, with no staff present to monitor the area. This was observed on a specific date when the front doors were open, and no staff were within visualization of the entrance. The Nursing Home Administrator confirmed that there was no staff assigned to monitor the unsecured front doors, posing a risk that a resident could exit the facility unnoticed. This lack of supervision and security at the main entrance was acknowledged by the facility's administration during the surveyor's questioning.
Failure to Administer Prescribed Supplemental Oxygen
Penalty
Summary
The facility failed to administer supplemental oxygen as prescribed by the physician for a resident. Clinical record review revealed an active physician's order dated January 12, 2023, instructing staff to administer supplemental oxygen via a nasal cannula at three liters per minute. However, observations on March 19, 2024, and March 21, 2024, revealed that the resident was receiving oxygen at a rate of two liters per minute. Interviews with a nurse aide and a licensed practical nurse confirmed the incorrect oxygen administration setting, which did not align with the physician's order.
Failure to Initiate Behavioral Health Treatments
Penalty
Summary
The facility failed to ensure necessary behavioral health treatments were initiated for a resident. The clinical record review revealed that the resident exhibited multiple documented behaviors, including inappropriate sexual behaviors and disruptive actions, from August 9, 2023, until October 24, 2023. A psychiatric evaluation on October 24, 2023, resulted in a new order for the resident to start Prozac 10 mg daily. However, this new order was noted by nursing staff on October 30, 2023, but was not added to the resident's medication regimen until November 23, 2023, a month after it was ordered. The Director of Nursing confirmed these findings during an interview on March 21, 2024.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a medication error rate of 5.56 percent based on 36 medication opportunities with two medication errors. During a medication administration pass, a licensed practical nurse (LPN) opened a Tolterodine Tartrate ER capsule and mixed its contents with applesauce before administering it to the resident, contrary to the physician's order and the medication package instructions, which specified that the capsule should be swallowed whole and not crushed or chewed. Additionally, the same LPN administered a Trelegy Ellipta inhaler to the resident without following the proper post-administration instructions. The resident was supposed to rinse her mouth with water and spit it out after using the inhaler, as per the physician's order and manufacturer's instructions. Instead, the resident took a drink and swallowed the liquid immediately after administration, and did not rinse her mouth as directed. These actions were confirmed through observation, clinical record review, and staff interview.
Failure to Ensure Safe and Sanitary Storage of Personal Food Items
Penalty
Summary
The facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for one of two nursing units. Specifically, in Resident 57's room, a personal refrigerator was found with outdated temperature monitoring logs and expired food items. The temperature monitoring log was last completed in April 2023, and the refrigerator contained items such as an opened bottle of ranch dressing with a use-by date of November 24, 2022, single-serve lemonade cartons with a use-by date of March 15, 2024, and a cheese stick with a use-by date of July 26, 2023. Additionally, the freezer section had ice encasing two single-serve containers of ice cream with unknown use-by dates, and there were undated squares of homemade peanut butter fudge on top of the refrigerator that were dried and hard. These observations were confirmed by Resident 57's family member. Further inspection on a subsequent date with the Director of Nursing (DON) revealed additional expired items, including an open container of butter with a use-by date of September 28, 2023, and a bag of peanuts with a use-by date of July 23, 2023, found on Resident 57's wheelchair. The DON confirmed these observations. The facility's policy on foods brought by family/visitors, last reviewed without changes on November 17, 2023, states that perishable foods should be discarded on or before the use-by date and any food showing signs of potential foodborne danger should be discarded by nursing or food service staff. The facility failed to adhere to this policy, leading to the deficiency noted in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 73 citations issued within 25 miles in the last 12 months — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mifflintown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Locust Grove Retirement Village | 4.7 mi | ★★★★★ | 0 | 0 |
| Greenwood Center For Rehabilitation And Nursing | 11 mi | ★★★★★ | 20 | 0 |
| William Penn Nursing And Rehab | 11.1 mi | ★★★★★ | 9 | 0 |
| Richfield Healthcare And Rehabilitation Center | 14 mi | ★★★★★ | 13 | 0 |
| Premier At Perry Village For Nursing And Rehab, Ll | 16.1 mi | ★★★★★ | 14 | 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.