Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Cambridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment, contractures, and dependence on staff for ADLs were observed lying in bed with Hoyer slings under their upper torsos, uncovered, with bed covers at the foot of the bed, while the room door was open and the privacy curtain not drawn. A CNA acknowledged leaving the room to obtain assistance with transferring them and stated they should have been covered for privacy and dignity. The ADON confirmed residents should be covered to promote dignity, and facility policy required maintaining body privacy and shielding residents from passers-by with a closed door or drawn curtain.
A resident with dementia, severe cognitive impairment, and documented need for substantial assistance with toileting was found wearing a pull-up over a brief that was heavily soiled with urine, with her clothing visibly wet. A CNA reported that the family had taken the resident to the bathroom and had double briefed her, and the CNA did not subsequently check the resident for toileting or incontinent care needs, despite stating that residents should receive incontinent care about every 2 hours. The family member reported routinely providing the resident’s care when present, double briefing at the resident’s request, and having previously complained that staff did not change the resident’s brief for hours, while the ADON acknowledged staff remained responsible to follow up on toileting even when family assisted.
Two residents did not receive care consistent with the facility’s infection control and incontinence policies. One cognitively impaired, fully incontinent resident was found in double briefs that were heavily soiled with urine, despite a care plan requiring disposable briefs and timely checks and changes; the assigned CNA did not verify toileting or incontinence needs after a family visit and relied only on asking if everything was okay. Another resident with intact cognition, total incontinence, and a colostomy was on enhanced barrier precautions, yet two CNAs provided incontinence care wearing only gloves, did not don gowns, used hand sanitizer instead of germicidal wipes to clean the bedside table, brought linen from another resident’s room, and performed perineal care using the same wipes in a back-and-forth motion rather than front-to-back with single-use wipes, contrary to EBP and infection control training.
A resident with hemiparesis, osteoporosis, reduced mobility, and prior femur fracture was care planned and documented on the MDS/Kardex as needing "staff assistance" for bed mobility, toileting, and bathing, but the care plan did not specify whether a 1‑person or 2‑person assist was required. Facility staff, including the MDS team and DON, reported that "staff assistance" was generally interpreted as a 1‑person assist and that the number of staff used was informally adjusted based on staff strength and the resident’s condition. During incontinent care using a mobility bar, a CNA provided a 1‑person assist; the resident rolled off the bed and sustained a comminuted intra‑articular distal femur fracture, with the resident later reporting that assistance for such care had alternated between one and two staff members.
A resident with hemiparesis, osteoporosis, reduced mobility, and a history of falls, who was care planned as dependent for bed mobility and at risk for falls, fell from bed during a bed bath and incontinence care provided by one CNA while using a mobility bar for turning. The resident reported that staff were not following protocol and that two staff were needed for turning, and staff interviews confirmed that assistance during bed baths and incontinent care alternated between one and two staff. After the witnessed fall, the resident initially complained of shoulder pain and later reported bilateral leg and knee pain; shoulder and lower-extremity x-rays were read as negative, but a subsequent CT scan at the hospital showed a comminuted intra-articular distal femur fracture. The family member stated they were not informed of the fall and requested hospital evaluation when the resident continued to complain of leg pain. The deficiency centers on the failure to keep the environment as free of accident hazards as possible and to provide adequate supervision during care, consistent with the facility’s fall management policy.
The facility failed to maintain clean and sanitary rooms and restrooms for multiple residents with significant cognitive and physical impairments. Surveyors observed a shared restroom with a glove on the floor and feces on a toilet seat riser on repeated checks, and another shared room with crumbs, utensils on the floor, dried brown substances in the toilet bowl, and soiled briefs left on the restroom floor. A family member reported routinely finding one resident’s room dirty, with an unmade bed and clothes on the floor, and stated she often cleaned the room herself. Housekeeping staff, the housekeeping supervisor, and the DON confirmed that housekeeping and CNAs shared responsibility for cleaning rooms, restrooms, and removing trash and soiled briefs, and acknowledged that unremoved trash and soiled items could contribute to infection. Despite a written homelike environment policy requiring cleanliness and order, these observations showed that the facility did not ensure thorough cleaning and sanitation in the affected rooms.
A resident with multiple comorbidities and intact cognition had PRN orders for Tylenol for pain and was documented as having significant pain on the MAR, but the MAR did not show that Tylenol was administered despite a nursing progress note stating that APAP was given and tolerated. The LVN later reported she had administered Tylenol and likely recorded it only in a personal paper tablet, and the DON confirmed that medications are expected to be documented on the MAR at the time of administration, resulting in incomplete and inaccurate clinical records.
A resident with profound intellectual disabilities and multiple complex medical conditions did not have PASRR evaluation recommendations incorporated into their assessment and care planning. The facility failed to submit a required NFSS request for specialized services following an IDT meeting, and staff interviews revealed a lack of awareness and communication regarding the recommendation for a prosthetic device. This resulted in the omission of necessary documentation and referral for specialized services.
A medication aide administered a phosphate-binding medication to a resident with end stage renal disease without ensuring it was given with food, as required by the physician's order and medication label. The resident had not eaten recently and no food was provided at the time of administration, resulting in a failure to follow prescribed medication administration procedures.
Surveyors found that an open, undated bag of macaroni and a disposable plastic cup left in a cornmeal container were present in the kitchen, contrary to facility policy requiring all opened food items to be dated and properly stored. Staff and management confirmed these actions were not in line with safe food handling practices and could lead to cross-contamination.
Two staff members failed to wear appropriate PPE while providing direct care to a resident with a tracheostomy on Enhanced Barrier Precautions, despite clear signage and facility policy requiring gown and glove use for high-contact care activities. Leadership was unaware of the lapse until shown video evidence, and both the DON and ADON/IP confirmed that PPE was required in these circumstances.
A resident with multiple comorbidities developed a Stage 3 sacral wound due to inadequate pressure ulcer care and prevention measures. The facility failed to implement effective interventions, resulting in worsening skin conditions. Observations showed a lack of proper offloading and timely incontinent care, and staff interviews revealed inconsistencies in wound care practices and documentation.
A resident with multiple health conditions, including spinal stenosis and diabetes, developed a sacral wound and MASD, but the facility failed to update the care plan to address these issues. Despite the resident's high risk for skin breakdown, the care plan was not revised to include the sacral wound, leading to a deficiency in care. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition.
A resident developed a Stage IV sacral pressure ulcer and a deep tissue injury on the left heel while under the care of a facility. Despite having a care plan, the facility failed to prevent the deterioration of the resident's condition, leading to debridement and hospitalization. The facility did not timely intervene or notify a wound care specialist, resulting in the resident developing sepsis due to MRSA and sacral osteomyelitis.
Failure to Maintain Privacy and Dignity for Two Dependent Residents
Penalty
Summary
The deficiency involves failure to maintain personal privacy and dignity for two residents who were dependent on staff for activities of daily living. One resident was an older female with hemiplegia and hemiparesis following a cerebral infarction, contractures of the upper and lower body, dysphagia, and a BIMS score of 0 indicating severely impaired cognition. Her care plan included staff participation in dressing due to an ADL self-care performance deficit. During observation, her room door was open, the privacy curtain was not drawn, and she was lying in bed on her back with the head of the bed lowered, wearing a gown with a Hoyer lift sling under her upper torso. She was uncovered, with bed covers at the foot of the bed, and was not interviewable. The second resident was an older female with dementia, osteoarthritis, anxiety, joint contractures, and a BIMS score of 3, also indicating severely impaired cognition, and was dependent on staff for ADLs. Her care plan included an intervention to close the curtain while providing care to protect her right to health, safety, and dignity. Observation showed her door open, curtain not pulled, lying on her back with the head of the bed lowered, wearing a gown with a Hoyer sling under her upper torso, and uncovered with covers at the foot of the bed. CNA A, who had been working at the facility for a year, entered the shared room and acknowledged that both residents should have been covered for privacy and dignity, stating she had left the room to get assistance with getting them out of bed. The ADON confirmed that residents should be covered and not exposed to promote dignity, and the facility’s Resident Rights/Dignity and Respect policy required maintaining privacy of the resident’s body and shielding residents from passers-by with a closed door or drawn curtain.
Failure to Provide Timely Incontinent Care and Maintain Continence Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who was continent on admission received services and assistance to maintain continence and appropriate incontinent care. The resident was an elderly female with diagnoses including anxiety, need for assistance with personal care, history of falls, osteoarthritis, and dementia, with a BIMS score of 3 indicating severely impaired cognition. Her quarterly MDS documented that she required substantial/maximal assistance with toileting hygiene and lower body dressing and was always incontinent of urine and bowel. Her comprehensive care plan identified an ADL self-care performance deficit related to cognitive deficit, dementia, and history of falls, with an intervention requiring staff participation with personal hygiene and oral care. On the day of observation, the resident was seen sitting in a recliner and was alert to name but not place or time. When asked, she stated she believed her brief was wet but then said she did not know, and there was no urine odor at that time. A CNA reported that she had taken the resident to the bathroom about 30 minutes earlier and that the resident could stand with one-person assistance. At the surveyor’s request, the CNA assisted the resident to the bathroom via wheelchair. When the resident stood from the recliner, the back of her pants was observed to be wet. In the bathroom, when the CNA pulled down the resident’s pants, the resident was found to be wearing a pull-up brief over another brief, and the inner brief was heavily soiled with urine, although the resident’s skin remained intact. The CNA stated that the resident was a “heavy wetter” and that it was the resident’s family member who had double briefed her. The CNA said she only took the family member to the bathroom and that the family member had taken the resident to the bathroom, and she did not check the resident to see if she required incontinent care or needed to use the bathroom. The CNA reported that she typically checked on residents needing assistance every 1½ to 2 hours and acknowledged the importance of providing incontinent care at least every 2 hours to avoid rashes and soiled clothing. The resident’s family member later reported that she had taken the resident to a dental appointment, returned her to the facility late morning, took her to the bathroom, and double briefed her at the resident’s request because the resident did not want her clothes to get wet. The family member also stated that she often did everything for the resident when present, had concerns that staff did not change the resident’s brief in a timely manner, and had previously reported to the facility that staff sometimes did not enter the room for hours to change the resident. The ADON stated that even when a family member says they will take a resident to the bathroom, staff should follow up to ensure the resident’s needs are met and that incontinent care should be provided at least every 2 hours, consistent with facility policies on incontinence and quality of life.
Failure to Follow Infection Control and Incontinence Care Practices for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program and to provide appropriate incontinence care for two residents. For one resident with dementia, severe cognitive impairment (BIMS score of 3), osteoarthritis, a history of falls, and total incontinence of bowel and bladder, the care plan required use of disposable briefs and checking and changing as indicated, with monitoring for signs and symptoms of UTI. On the survey date, this resident was observed sitting in a recliner, alert only to name, and stated she believed her brief was wet but was unsure. A CNA reported having taken the resident to the bathroom about 30 minutes earlier and stated the resident was checked every 1.5 to 2 hours. When the CNA assisted the resident to the bathroom at the surveyor’s request, the back of the resident’s pants was observed to be wet, and the resident was found wearing a pull-up brief over another brief that was heavily soiled with urine, although the skin remained intact. Further interviews revealed discrepancies in the timeline of care and who provided toileting assistance. The CNA stated that the resident’s family member had taken the resident to the bathroom and that the family member had doubled briefed the resident, and the CNA did not verify whether the family member had actually taken the resident to the bathroom or check the resident for incontinence. The CNA acknowledged she only asked if everything was okay and did not assess whether the resident needed incontinence care or toileting. The family member later reported that she had taken the resident to a dental appointment and returned her to the facility, took her to the bathroom once, and doubled briefed her because the resident did not want her clothes to get wet. The family member also reported ongoing concerns that staff did not change the resident’s brief in a timely manner and that she had previously notified the facility about long periods without staff entering the room. The resident was later evaluated at the hospital for altered mental status, with urinalysis showing bacteria in the urine and subsequent orders for a UA C&S and Nitrofurantoin for UTI. For another resident with intact cognition (BIMS score of 13), cerebral infarction, a femur fracture, reduced mobility, muscle weakness, and total incontinence of bowel and bladder with a colostomy, the care plan included checking as required for incontinence. The resident’s room had enhanced barrier precautions (EBP) signage and a PPE hanger with germicidal wipes, gloves, masks, and disposable gowns. During observed incontinence care, two CNAs washed their hands and donned gloves but did not wear disposable gowns despite the EBP signage. One CNA went into another resident’s room, took large towels from that room, and brought them into this resident’s room to use as linen. The same CNA removed items from the bedside table and attempted to disinfect the table using hand sanitizer instead of the available germicidal wipes. During perineal care, the CNAs used the same wipes repeatedly, cleaning the groin, perineal area, and buttocks back and forth rather than using one wipe at a time and wiping from front to back. Interviews with the CNAs confirmed that they did not follow EBP and infection control practices. One CNA stated she did not think she needed a gown and only realized after reading the EBP sign that a disposable gown was required to protect herself and the resident from bacteria. She acknowledged that taking linen from one resident’s room to another was not acceptable due to cross-contamination risk and that she used hand sanitizer on the bedside table because it was available, forgetting to use the germicidal wipes. She also stated she had been taught to wipe from front to back with one wipe at a time to prevent infection. The other CNA stated she knew residents on EBP required gowns and gloves and that linen should not be moved between rooms, and she acknowledged that perineal care should be done upward and away, not back and forth, to prevent introducing bacteria into the vaginal area. The ADON, serving as Infection Preventionist, confirmed that staff had been in-serviced on infection control, handwashing, cleaning and disinfecting surfaces with germicidal wipes, and EBP, and stated that staff should provide incontinence care at least every two hours, wear appropriate PPE for residents on EBP (including those with colostomies), avoid moving linen between rooms, and clean from front to back during incontinence care. Facility policies on infection control and incontinence required staff to minimize the spread of infections and provide appropriate treatment to prevent infections.
Failure to Specify Bed Mobility Assistance Level in Care Plan Resulting in Fall Injury
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with clear, measurable objectives and time frames for a resident’s bed mobility needs. The resident was an older female with multiple significant diagnoses, including cerebral infarction with hemiplegia/hemiparesis on the left non-dominant side, lack of coordination, reduced mobility, osteoporosis, muscle weakness, and a prior displaced comminuted fracture of the left femur. Her comprehensive MDS showed intact cognition (BIMS 14) and documented that she was dependent on staff for rolling left and right, with the helper doing all of the effort or requiring assistance of two or more helpers. The care plan and Kardex, however, only stated that she required “staff assistance” for bed mobility and did not specify whether she required a 1‑person or 2‑person assist. On the date of the fall, the resident’s care plan included problem areas such as ADL self‑care performance deficit related to functional decline and contractures, positioning support devices (HALO and 1/4 siderails), and risk for falls related to history of falls, hypotension, and generalized weakness. Interventions for bed mobility stated only that she required staff assistance for bed mobility (rolling left and right, sit to lying, lying to sitting), without clarifying the number of staff needed. The MDS and Kardex were based on section GG and also reflected that she was dependent for toileting, showering/bathing, and rolling, but again did not distinguish between 1‑person and 2‑person assist. Interviews with the MDS Coordinator, MDS Resource Coordinator, and DON confirmed that the facility’s practice was to interpret “staff assistance” as 1‑person assist, with the number of staff informally adjusted depending on the CNA’s strength and the resident’s condition on a given day, rather than being explicitly defined in the care plan. During the incident, a CNA provided a bed bath and incontinent care to the resident using the mobility bar (HALO). The CNA reported that after completing the bed bath, she positioned the resident on her right side, with the resident holding the mobility bar, and asked the resident multiple times if she had a firm grasp. As the CNA placed an adult brief under the resident, the resident rolled off the bed and landed on her left side. Progress notes documented that the resident fell from the bed while using the mobility bar, with vital signs stable and initial complaints of pain to the left side. Subsequent notes showed ongoing complaints of bilateral leg, knee, and ankle pain, and imaging eventually revealed a comminuted, mildly impacted, intra‑articular fracture of the distal left femur, requiring a leg immobilizer. The resident later stated that sometimes one staff member and sometimes two staff members assisted her with bed baths and incontinent care, and that the aide involved in the fall was not following protocol. Facility leadership acknowledged that the Kardex and care plan did not specify 1‑person versus 2‑person assist and that aides were expected to infer this from the generic “staff assistance” designation.
Failure to Prevent Fall and Injury During Bed-Level Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision during incontinence care, resulting in a resident’s fall and subsequent femur fracture. The resident was an older female with multiple significant diagnoses, including prior cerebral infarction with hemiplegia/hemiparesis on the left side, osteoporosis, reduced mobility, muscle weakness, lack of coordination, and a prior displaced comminuted fracture of the left femur. Her comprehensive and quarterly MDS assessments documented that she was dependent on staff for rolling left and right in bed and had a history of falls with major injury. Her care plan identified ADL self-care performance deficits, need for staff assistance with bed mobility and colostomy/incontinent care, and a requirement for two-person assistance with transfers using a Hoyer lift, as well as fall risk related to history of falls, hypotension, and generalized weakness. On the date of the incident, the resident was receiving a bed bath and incontinent care from one CNA. According to the ADON’s progress note, during the bed bath the resident used a mobility bar to turn and misjudged the width of the bed, causing her momentum to roll off the bed before staff could stop her, and she landed on the floor on her left side. The CNA later stated she had finished the bed bath and was positioning the resident on her right side to apply an adult brief while the resident held the mobility bar. The CNA reported asking the resident three times if she had a firm grasp on the bar, and as soon as she placed the brief under the resident, the resident rolled off the bed and landed on her left side in a seated position. The resident reported that the CNA was applying lotion to her legs before she was pushed out of bed, clarified that she did not believe it was intentional, and stated that the CNA was not following protocol. The resident also stated that there needed to be two people when turning her and that sometimes one staff member and sometimes two staff members assisted her with bed baths and incontinent care. Following the fall, nursing staff documented that the event was witnessed and that the resident initially complained of shoulder pain. Vital signs were taken, and an x-ray of the left shoulder was ordered and later read as showing no fracture or acute abnormality. Another nurse reported performing range of motion on both arms and legs, checking the resident’s head, and obtaining vital signs at the time of the fall but did not document this assessment because the resident was not on her assignment. Over the next days, the resident complained of bilateral leg, knee, and ankle pain, and the NP ordered STAT x-rays of both femurs, knees, and ankles, which were read as showing osteoporotic bones and osteoarthritis but no acute fractures or dislocations. The resident stated she complained of left leg pain for three days. Later, at the request of a family member due to ongoing leg/knee pain, the resident was sent to the hospital, where a CT scan of the left lower extremity revealed a comminuted, mildly impacted, intra-articular fracture of the distal femur. The family member reported not being informed of the fall and only learning of it before insisting on hospital evaluation. The facility’s fall management policy stated that residents are to receive appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs, but the report findings describe that the facility failed to prevent the fall during care and to keep the environment as free of accident hazards as possible for this resident.
Failure to Maintain Clean and Sanitary Resident Rooms and Restrooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, specifically by not thoroughly cleaning and sanitizing resident rooms and restrooms in the 100 hall. For one resident with severe cognitive impairment, osteomyelitis, diabetes with neuropathy, muscle weakness, and frequent incontinence, and another resident with severe cognitive impairment, Alzheimer’s disease, heart failure, and occasional incontinence, surveyors observed their shared restroom on multiple occasions. The restroom contained a pink latex glove on the floor beside the toilet and a toilet seat riser with a dry brown substance on the seat, later identified as feces. These conditions were observed both when the residents were out of the room and when they were present, and the feces remained on the toilet seat riser over several observations. Two additional residents, one with intact cognition but dementia, diabetes, polyneuropathy, and muscle weakness, and another with moderate cognitive impairment, diabetes, CKD stage 3A, anemia, and muscle weakness, were also found to be living in an unclean environment. Their shared room had crumbs and a white plastic spoon on the floor, and the restroom toilet bowl had a dried brown substance. A pair of soiled briefs was observed on the restroom floor in the corner. A family member of one of these residents reported that every time she visited, the room was dirty, the bed was not made, and the resident’s clothes were on the floor, and that she often ended up cleaning the room herself, sometimes finding the room dirty even when visiting twice in one day. Interviews with housekeeping staff and facility leadership confirmed that housekeeping staff were responsible for cleaning resident rooms and restrooms, sanitizing tables, cleaning toilets, and removing trash, and that CNAs shared responsibility for removing trash and bagging soiled briefs. The housekeeper assigned to the 100 hall acknowledged that trash and soiled clothing lying around in resident rooms could be hazardous and could lead to infection. The housekeeping supervisor and DON stated that housekeeping staff did not clean when food was being served on the hall and that some rooms required cleaning twice a day, with CNAs expected to notify housekeeping when residents removed dirty briefs. Despite these stated responsibilities and policies, including a homelike environment policy requiring cleanliness and order, the observed conditions in the four residents’ rooms and restrooms demonstrated that the facility failed to ensure thorough cleaning and sanitation. The facility’s homelike environment policy dated October 2009 stated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including cleanliness and order. However, the persistent presence of feces on toilet surfaces, dried brown substances in toilet bowls, soiled briefs on restroom floors, and general room clutter and debris showed that this policy was not effectively implemented in the affected rooms on the 100 hall.
Incomplete MAR Documentation for PRN Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident receiving pain management. The resident was an older female with multiple significant diagnoses, including cerebral infarction with resulting hemiplegia/hemiparesis, reduced mobility, osteoporosis, muscle weakness, and a history of a displaced comminuted fracture of the left femur. Her comprehensive and quarterly MDS assessments showed intact cognition (BIMS 14) and documented that she received scheduled and PRN pain medications and non-medication interventions for pain. Physician orders included monitoring pain every shift using a 1–10 scale and PRN orders for Meloxicam and Tylenol 325 mg, two tablets by mouth every six hours as needed for mild pain. Following a fall from bed on 1/6/26, a progress note documented that she complained of pain to her left side and was medicated for discomfort. On 1/8/26, the Medication Administration Record (MAR) documented a pain level of 8 for the resident on the night shift (Nocs), but there was no corresponding documentation on the MAR that Tylenol 325 mg was administered that day. A progress note entered on 1/9/26 by an LVN stated that the resident, status post fall, complained of knee pain during the shift and was medicated once with APAP 325 mg as ordered, which she tolerated well. In an interview, the LVN reported that she gave Tylenol when the resident reported pain of 8, that the resident’s pain decreased and she likely went to sleep, and that failure to document on the MAR was probably an oversight, despite having noted it in her paper tablet. The DON stated that her expectation was that nurses document medication administration on the MAR at the time it is given. Facility documents, including the LVN job description and the documentation policy, describe the requirement to complete charting and maintain a concise account of treatment, care, and resident response, underscoring that the missing MAR entry for the administered Tylenol constituted incomplete and inaccurate clinical documentation.
Failure to Incorporate PASRR Recommendations and Submit NFSS Request
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident's assessment, care planning, and transition of care. Specifically, the facility did not submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC online portal within 20 days after the Interdisciplinary Team (IDT) meeting, as required. This omission was identified for one resident who was PASRR positive for intellectual disability and had a recommendation for a prosthetic device documented in the Person-Centered Service Plan (PCSP). Record review showed that the resident had multiple complex diagnoses, including profound intellectual disabilities, cerebral palsy, contractures, and was totally dependent on activities of daily living. The resident's care plan acknowledged the PASRR assessment and the need for specialized services, but there was no evidence in the clinical record that the NFSS form was completed or submitted. Interviews with facility staff revealed a lack of awareness and communication regarding the PCSP recommendation for a prosthetic device, with the MDS coordinator and RN both stating they were not aware of the recommendation at the time of the meeting. The physical therapist also indicated that no device was recommended during the PASRR meeting. The facility's policy requires that all residents be properly screened using PASRR and that referrals for specialized services be made to the appropriate state agencies. However, in this case, the process was not followed, and the required documentation and referral for specialized services were not completed. Staff interviews confirmed that the failure to submit the NFSS could prevent residents from receiving necessary services for their wellbeing.
Failure to Administer Medication as Ordered with Required Food
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications as ordered for a resident with end stage renal disease and type 2 diabetes mellitus with chronic kidney disease. Specifically, the medication Sevelamer Carbonate, prescribed to be taken with meals to control phosphorus levels, was administered by a medication aide without food, contrary to the physician's order and the instructions on the medication container. During observation, the medication aide gave the resident two tablets of Sevelamer Carbonate in the resident's room where no food or snacks were present. The resident confirmed that he had eaten lunch much earlier and would not have dinner until later, and the aide did not inquire about the availability of snacks or offer food at the time of administration. The medication administration record showed the medication was documented as given at that time, and the aide later acknowledged not following the special instructions due to being observed during the process. Interviews with the facility pharmacist, hemodialysis nurse, nurse practitioner, and director of nursing confirmed that Sevelamer Carbonate requires administration with food for proper absorption, as indicated by the physician's order and medication label. The facility's policy also requires medications to be administered as prescribed, including any special instructions. The failure to administer the medication with food constituted a deviation from both the physician's order and facility policy.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
During a kitchen inspection, surveyors observed that a half-used bag of uncooked enriched macaroni was left open and undated in the dry storage area. Additionally, a disposable plastic cup was found left inside a large container of cornmeal. These practices were not in accordance with the facility's food storage policy, which requires all opened containers to be dated and sealed or covered during storage. Interviews with dietary staff, the dietary manager, and the administrator confirmed that all food items should be dated upon opening and that leaving a disposable cup in a food container is not permitted due to the risk of cross-contamination. The facility's own policy, last revised in July 2014, specifies that opened containers must be dated and properly sealed or covered. The observed failures in food storage and handling could place residents at risk of cross-contamination and foodborne illness.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions for a resident requiring such measures. Specifically, two staff members, identified as Unknown A and Unknown B, did not wear the appropriate personal protective equipment (PPE) while providing direct care to a resident with a tracheostomy who was on Enhanced Barrier Precautions. Video monitoring screenshots showed that one staff member did not wear a mask or gown, and the other did not wear a gown during high-contact care activities. The resident involved had significant medical conditions, including anoxic brain damage, respiratory failure, type 2 diabetes with hyperglycemia, Alzheimer's disease, chronic kidney disease stage 3, tracheostomy status, persistent vegetative state, unspecified dementia, and aphasia. The care plan for this resident specifically required the use of Enhanced Barrier Precautions due to the tracheostomy, and signage was posted on the resident's door outlining the required PPE for high-contact care activities. Despite these measures, staff failed to comply with the established protocols. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed that staff are required to don and doff PPE when providing care to residents on Enhanced Barrier Precautions. Both leaders were unaware that staff had failed to use the required PPE and acknowledged that such lapses could result in the spread of infection. Review of the facility's infection control policy further supported the requirement for PPE use during high-contact care activities for residents on Enhanced Barrier Precautions.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for a resident, leading to the acquisition of a Stage 3 sacral wound. The resident, who was bedfast and had multiple comorbidities including spinal stenosis, diabetes, and congestive heart failure, was admitted with a red area on the groin or buttock. Despite being at high risk for pressure ulcers, the facility did not implement effective interventions to prevent skin breakdown or promote healing of existing wounds. The care plans for the resident did not adequately address the sacral wound, and there was a lack of documentation and timely intervention for the moisture-associated skin damage (MASD) and incontinence-associated dermatitis (IAD) observed in the groin area. Observations revealed that the resident was often found in a supine position without proper offloading measures, and there were significant gaps in the documentation of repositioning and incontinent care. The Braden Scale assessments indicated a high risk for pressure ulcers, yet the facility did not consistently follow through with necessary preventive measures. Interviews with staff revealed inconsistencies in wound care practices and communication. The wound care nurse and other staff members were aware of the resident's skin issues but failed to document and address them adequately. The wound care doctor noted that the sacral wound worsened after the resident's return from the hospital, and there was a lack of adherence to repositioning and offloading recommendations. The facility's failure to provide timely and effective care placed the resident at risk for further skin breakdown, infection, and pain.
Failure to Update Care Plan for Resident with Sacral Wound and MASD
Penalty
Summary
The facility failed to ensure that the care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for a resident who had a sacral wound and moisture-associated skin damage (MASD) to the groin. The care plan did not accurately address the sacral wound, which was a significant oversight given the resident's condition and risk factors. The resident, a male with multiple diagnoses including spinal stenosis, dysphagia, Type 2 Diabetes, congestive heart failure, and chronic kidney failure, was bedfast and at high risk for skin breakdown. Despite the presence of a sacral wound and MASD, the care plan was not updated to reflect these conditions. The care plan dated 4/1/2024 only addressed the risk of skin breakdown due to incontinence, and subsequent care plans failed to include the sacral wound, even as it progressed. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's skin conditions. The Wound Care Nurse was aware of the sacral wound and MASD but did not ensure the care plan was updated. The Director of Nursing and Executive Director were also unaware of why the care plan did not address the sacral wound, indicating a breakdown in the facility's processes for updating care plans in response to significant changes in a resident's condition.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a Stage IV sacral pressure ulcer and a deep tissue injury on the left heel for a resident who was admitted without pressure ulcers. The resident, who had multiple medical conditions including encephalopathy, hypertension, and cognitive impairment, developed these pressure injuries while under the care of the facility. Despite having a care plan that included interventions such as an air mattress, repositioning, and skin assessments, the resident's condition worsened, leading to debridement and hospitalization. The facility did not timely intervene when the resident's Stage IV pressure ulcer continued to deteriorate. The resident was not sent to the hospital promptly and was only suggested for hospice care. Additionally, the facility failed to notify a wound care specialist physician about the worsening condition of the pressure ulcer, resulting in a lack of evaluation and modification of the wound treatment for 12 days. This inaction contributed to the resident's development of sepsis due to MRSA, sacral osteomyelitis, and the worsening of the sacral pressure ulcer. The facility's records indicate that there were inconsistencies in the completion of prescribed treatments, such as the use of a low air loss mattress and preventive skin care. The resident's weight loss and nutritional intake were also inadequately monitored, which may have contributed to the deterioration of the pressure ulcers. The lack of timely and appropriate interventions placed the resident at risk of further skin breakdown, infection, and pain.
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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 Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richmond Health Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Oak Bend Medical Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Rosenberg Health & Rehabilitation Center | 2 mi | ★★★★★ | 5 | 1 |
| Paradigm At The Brazos | 2 mi | ★★★★★ | 0 | 0 |
| Fort Bend Healthcare Center | 4.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.