Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regalcare At Courtyard-medford during CMS and state inspections, most recent first.
A resident with a history of chronic lung disease and other serious conditions developed acute respiratory symptoms and was ordered a STAT chest X-ray by a nurse practitioner. Nursing staff failed to process the order, did not contact the radiology provider, and did not inform the practitioner of the missed test. The X-ray was never obtained, and the radiology company was not notified while the resident was still at the facility.
Several residents with severe cognitive impairment and total dependence on staff for toileting and repositioning did not receive timely incontinence care or repositioning as required by their care plans and physician orders. Documentation and staff interviews revealed frequent missed care, with residents left soiled for extended periods and pressure wounds deteriorating as a result. Staff cited chronic short staffing as a reason for these lapses, and facility leadership acknowledged that the lack of timely care constituted neglect.
Multiple residents with pressure ulcers did not receive timely or appropriate wound care, with delays in implementing wound care orders, missed incontinence care and repositioning, and improper use of support surfaces. One resident's wounds deteriorated significantly due to these failures, and other residents experienced similar lapses, including incorrect wound care frequency and lack of physician orders for support surfaces. Staff interviews and documentation confirmed these deficiencies, which were linked to chronic understaffing and lack of proper monitoring.
Three residents did not receive timely or appropriate care for wounds or infections, including delayed wound treatment, failure to implement wound care recommendations, delayed antibiotic administration, and lack of required skin assessment documentation. These failures resulted in worsening conditions and were not in accordance with professional standards or care plans.
Surveyors found widespread environmental deficiencies throughout the facility, including damaged ceiling and floor tiles, holes in walls, broken blinds, and missing closet doors, with many issues unreported in maintenance logs. A resident's heater cover remained broken and taped for years after being told by staff that repair was too costly, and staff interviews confirmed that many repairs were not documented or addressed in a timely manner.
The facility did not maintain an effective pest control program, as evidenced by daily reports and direct observations of mice and droppings in resident rooms and common areas. Despite a policy requiring regular inspections, sealing of entry points, and proper food storage, staff and residents reported ongoing issues with unsealed food, holes in walls, and infrequent pest control visits, resulting in persistent pest activity throughout the facility.
Multiple residents with severe cognitive impairment and total dependence on staff did not receive timely incontinence care, scheduled showers, or required assistance with self-feeding. Staff provided care only at set times rather than as needed, and documentation of care and refusals was lacking. Observations and interviews confirmed that understaffing contributed to missed care, and residents were left without necessary support for basic hygiene and nutrition.
Several residents with severe cognitive impairment did not receive individualized or appropriate activity programming as required by their care plans. Activity assistants failed to engage these residents in scheduled or adapted activities, often leaving them unengaged for extended periods and not providing one-on-one or sensory stimulation as documented in their care plans. The activity calendar was not followed, and staff did not offer necessary support or materials to facilitate participation.
A resident with dementia and paraplegia, dependent on staff for transfers, was found with a portable space heater placed on top of a trash can containing paper waste. The heater was provided due to a malfunctioning room heating system, but its use and placement violated life safety codes and created an accident hazard.
The facility did not maintain adequate nursing staff levels as outlined in its own assessment, resulting in missed care such as delayed repositioning, incontinence care, and feeding assistance. Multiple units were left with only one or no CNAs during overnight shifts, and staff and residents reported prolonged call light response times. Surveyors also observed several CNAs sleeping in resident areas during their shifts, despite facility policy prohibiting this behavior.
Surveyors found that none of the five nurses reviewed had documented wound care competencies, despite the facility's assessment indicating the need for such skills to care for residents with complex medical needs, including wounds. The DON confirmed that only verbal education was provided without competency assessment, and the Administrator acknowledged the expectation for demonstrated wound care competency.
The facility did not complete required annual performance reviews for five eligible CNAs, with some reviews overdue by several years and one CNA never having received a review. Both the DON and Administrator acknowledged the expectation for annual reviews but could not explain why they were not conducted.
Surveyors observed a medication error rate of 24.14% when three nurses administered multiple medications to three residents outside the required one-hour window from scheduled times. The late administrations involved various medications, including anticonvulsants, pain relievers, supplements, anticoagulants, and anxiolytics. All staff interviewed acknowledged the timing errors and confirmed knowledge of the facility's policy requiring medication administration within one hour of the scheduled time.
Surveyors found that food and drink served to residents were frequently not at safe or appetizing temperatures, with hot foods often served lukewarm and cold items sometimes only cool or partially frozen. Multiple residents expressed dissatisfaction with the taste and temperature of meals, and observations confirmed issues with food quality, delivery timing, and lack of condiments. Temperature checks showed that food was not consistently maintained at the expected standards upon reaching residents.
Surveyors observed multiple instances of improper food storage, including undated, unlabeled, and uncovered food items, as well as decomposing produce and visible mold in facility refrigerators and kitchenettes. Rusting and flaking shelving, expired or bulging milk containers, and failure to follow food safety policies were also noted. Staff interviews confirmed these practices did not meet required standards.
Two residents experienced deficiencies in medical record documentation: one did not have refusals or physician notifications documented when a cervical collar was not applied as ordered, and another had multiple shifts with missing CNA documentation for ADLs, despite facility policy and staff expectations for timely and complete charting.
Surveyors found that a resident with nephrostomy tubes had urinary drainage bags left exposed and not placed in privacy bags, despite being cognitively intact and dependent for bed mobility. Staff on two units were also observed referring to residents as "feeders" and speaking in a foreign language within earshot of residents, actions confirmed by the DON as inappropriate and not in line with facility policy.
Two residents with severe cognitive impairment were administered psychotropic medications—ramelteon and Depakote—without written informed consent from themselves or their health care proxies. In both cases, staff confirmed that written consent was required by facility policy but was not obtained, and only verbal consent was documented in one instance.
A resident with a neurological condition was found with a cup of medications left on their lunch tray for self-administration without having been assessed or care planned for this practice. Facility policy and staff interviews confirmed that medications should not be left at bedside unless a resident has been properly assessed, and that nurses are expected to remain with residents during medication administration.
A resident with severe cognitive impairment was found with a pillow placed under the fitted sheet and the bed positioned close to the wall, actions taken by staff to prevent the resident from sliding or rolling out of bed. Staff interviews confirmed the pillow was not used for comfort, and there was no documentation of a restraint assessment or physician's order, contrary to facility policy.
Two residents' MDS assessments were inaccurately coded, with one resident's bilateral upper and lower extremity contractures not documented and another resident's fall not recorded, despite supporting evidence in medical records and staff interviews.
Two residents did not receive care according to professional standards: one was not weighed daily as ordered for CHF management, and the physician was not notified of missed or refused weights; another was placed on an air mattress without a physician's order or care plan update, despite having a stage 3 pressure ulcer. Staff interviews confirmed these lapses in following physician orders and facility policy.
A resident who previously fed independently with set-up assistance became totally dependent on staff for feeding after a hospital stay. Despite this decline, no assessment or therapy intervention was initiated or documented to address the loss of self-feeding ability, and staff interviews confirmed that no referrals or evaluations were made by therapy disciplines.
A resident with a right hand contracture did not consistently receive the physician-ordered carrot orthosis, as staff failed to apply it and instead used makeshift substitutes like a napkin or washcloth. The resident reported lack of staff assistance and frequent loss of the orthosis, while staff interviews revealed no follow-up to replace the device or update care documentation.
A resident with dementia and severe cognitive impairment, who was dependent on staff, experienced significant weight loss and had physician orders for weekly weights. Despite these orders and facility policy, staff failed to obtain and document weekly weights, and the required interventions in the nutritional care plan were not followed, as confirmed by staff interviews and record review.
A resident with dementia and depression, who was cognitively intact, reported having broken teeth that needed attention. There was no documentation or consent indicating the resident had been seen by a dentist, and staff confirmed no in-house dental visit had occurred, resulting in a failure to provide necessary dental care.
The facility did not notify the state agency in writing about a recent change in the DON position, as required. The Administrator confirmed that the new DON started several months ago, but the required notice was not submitted through the HCFRS reporting system.
A facility failed to maintain complete and accurate medical records for three residents, as CNA Activity of Daily Living (ADL) Flow Sheets were often left incomplete or blank. Interviews revealed that CNAs struggled to complete documentation due to time constraints, and the Unit Manager and DON were unaware of the issue, despite facility policies requiring daily documentation completion.
A resident with multiple diagnoses, including amyloidosis and dysphagia, experienced a medical emergency and was found unresponsive with food in their mouth. CPR was initiated, but the Unit Manager failed to document the presence of food, violating the facility's policy on maintaining complete medical records.
A resident with ESRD did not receive scheduled dialysis due to a communication breakdown at the facility. The resident, who required dialysis three times a week, missed treatments when the facility's dialysis center was closed, and a rescheduled session was not communicated effectively. This resulted in the resident experiencing mental status changes and requiring transfer to the hospital for dialysis.
The Facility failed to maintain accurate medical records for two residents. One resident lacked documentation of a physician's order for hospital transfer, while another resident's weekly skin assessments were not consistently documented. The Regional Nurse Consultant confirmed these documentation lapses.
The facility failed to notify attending physicians of omitted medication doses for 13 residents during a specific shift. Critical medications, including antihypertensives and insulin, were not administered, and there was no documentation of physician notification. Interviews revealed that the Unit Manager was unable to administer all medications due to staffing issues, and the omissions were not reported to physicians as required by policy.
A LTC facility failed to administer critical medications to 13 residents during a shift, including insulin and antihypertensives, due to staffing issues. The omissions were not documented, and physicians were not notified, violating facility policy and federal regulations.
A resident with dementia and anxiety was found crying and physically restrained to a chair by their clothing, causing emotional distress. The resident was severely cognitively impaired and required supervision with mobility. The Director of Nursing conducted interviews, but no staff admitted to the act. The incident was reported to the family and police, and the involved employees were terminated.
A resident with dementia and severe cognitive impairment was found restrained to a chair by their clothing, causing them distress. The incident was discovered by a nurse, and the Director of Nursing confirmed that the resident could not have restrained themselves. The involved staff were terminated, and the incident was reported to the family and police.
The facility failed to meet professional standards of quality for four residents by not accurately transcribing physician's orders and not implementing the 24-hour chart check policy. Additionally, the facility did not obtain a physician's order for a suction machine for one resident and failed to document daily weights for another resident as ordered.
The facility failed to provide proper respiratory care for four residents by not maintaining plans for nebulizer and CPAP machines and not changing oxygen tubing per physician's orders. Observations showed uncovered and outdated equipment, and staff confirmed the deficiencies.
The facility failed to maintain a medication error rate below 5%, with errors including administering the wrong form of a medication, administering medications late, and failing to check expiration dates. These errors impacted three residents and were confirmed by interviews with the nurses and the DON.
The facility failed to ensure medications and biologicals were stored in locked compartments, with multiple instances of unsecured medications at residents' bedsides, undated eye drops, and an unlocked medication room. Staff interviews confirmed these practices were against facility policy.
The facility failed to promote dignity and privacy for residents by not assisting them with eating and not providing privacy covers for a Foley catheter bag. Multiple residents were observed eating with their hands without staff intervention, and a Foley bag was left uncovered, visible to staff and a roommate.
A resident with dementia was administered psychotropic medications without obtaining the necessary consents from the healthcare proxy. Despite attempts to reach the proxy, the facility did not mail or fax the consents, leading to a failure in following the facility's policy on informing residents or their representatives about the medications.
A nurse left medications unattended with a resident to self-administer without a physician's order and an assessment for self-administration completed. The resident's medical record did not indicate any assessment for self-administration of medication, nor was there an active physician's order for self-administration. The DON confirmed that the resident had not been assessed for self-administration of medication.
The facility failed to develop and implement comprehensive care plans for two residents. One resident did not have a care plan for the use of a suction machine, and another resident was not wearing prescribed braces as indicated in their care plan. The Director of Nursing was unaware of these deficiencies.
The facility failed to provide necessary assistance with ADLs for a resident with dementia, who was observed eating with their hands and struggling with utensils without receiving the required cueing and support from staff. Despite being aware of the resident's decline, staff did not follow the care plan instructions, resulting in the resident's continued difficulty during meals.
A resident sustained bruises on their left arm that were not identified or documented by staff during daily care or weekly skin checks, despite having a care plan and physician's order for regular skin assessments. The resident, who had intact cognition and was dependent on staff for bathing, mentioned bumping their arm but did not inform the nurses. Nurse #10 confirmed the bruises had been present for about two weeks and should have been documented.
A resident experienced a significant decrease in range of motion (ROM) in the left hand, which went unnoticed by the facility staff. Despite the resident's cognitive intactness and no initial ROM impairment, the resident's left hand became contracted. The concern was not escalated by the CNA, and the nursing and rehabilitation staff were unaware of the issue until the surveyor's observation. An occupational therapy evaluation later confirmed the ROM deficit and recommended interventions.
A facility failed to provide care according to professional standards for a resident with a g-tube. The resident's enteral feeding bags were observed multiple times without proper labeling, making it impossible to determine when the bags were hung. Both a nurse and the DON confirmed that the bags should have been labeled with the necessary information.
The facility failed to provide emergency smooth clamps for four residents requiring renal dialysis, as required by their policy. Observations and interviews revealed that the clamps were not present in the residents' rooms or on their wheelchairs, despite the facility's policy mandating their availability at all times.
The facility failed to ensure pharmaceutical services met the needs of a resident with an overactive bladder by not administering the physician-ordered Myrbetriq on multiple occasions due to unavailability. Despite the facility's policy requiring immediate action to obtain the medication, necessary steps were not taken, and the DON was not informed in a timely manner.
The facility failed to complete the required Abnormal Involuntary Movement Scale (AIMS) assessments for two residents receiving antipsychotic medications. Despite facility policy mandating AIMS assessments every six months, the assessments for both residents were overdue, as confirmed by the Director of Nursing.
Failure to Obtain STAT Chest X-ray as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including chronic pulmonary disease, emphysema, chronic kidney disease, Alzheimer's disease, and lung cancer, developed acute respiratory symptoms. The nurse practitioner assessed the resident and ordered a STAT (immediate) chest X-ray due to concerns about respiratory congestion and the possibility of influenza, given recent cases in the facility. The order was entered into the electronic medical record, and facility policy required nursing staff to process such orders promptly and communicate with the radiology provider. However, the nursing staff failed to act on the STAT chest X-ray order. The nurse on duty was unaware of the order and did not contact the radiology company or follow up to ensure the test was performed. The subsequent shift nurse also did not follow up on the order after discovering it late in her shift. There was no documentation that the radiology provider was contacted, that the X-ray was obtained, or that the nurse practitioner was informed of the delay or inability to complete the order. Interviews with facility staff and the radiology company confirmed that no order for a STAT chest X-ray was received, and the test was never performed while the resident was present. The director of nursing and unit manager both indicated that the expected process was not followed, and the radiology company only became aware of the order days later, after the resident was no longer at the facility.
Failure to Provide Timely Repositioning and Incontinence Care Resulting in Neglect
Penalty
Summary
The facility failed to protect four residents from neglect by not providing necessary care related to repositioning and incontinence management. One resident with severe cognitive impairment and a history of functional urinary incontinence and dementia was dependent on staff for all toileting and repositioning needs. Despite care plans and physician orders requiring repositioning every 2-3 hours and regular incontinence care, documentation and interviews revealed that these interventions were frequently missed. The resident developed multiple pressure ulcers, which deteriorated over time, with documentation showing numerous missed shifts for both repositioning and toileting hygiene. The resident's health care proxy repeatedly reported concerns to facility leadership, but the issues persisted, and the resident was eventually hospitalized for a deteriorating pressure wound. Three additional residents, all with severe cognitive impairment and total dependence on staff for toileting, were also not provided with timely incontinence care. Observations showed that these residents remained in common areas for extended periods without being checked or changed by staff. Care plans lacked specific interventions or schedules for incontinence care, and staff interviews confirmed that care was often only provided in the morning and afternoon, with long gaps in between. Staff cited chronic short staffing as a barrier to providing timely care, and some residents were found to be soiled for prolonged periods. Interviews with CNAs, nurses, and facility leadership confirmed that the standard of care for incontinent residents was not met, with staff acknowledging that residents were often left in soiled briefs due to insufficient staffing and time. The facility's own policies defined neglect as the failure to provide necessary goods and services to avoid physical harm, and multiple staff members, including the Administrator, agreed that the lack of timely care constituted neglect. The documentation and interviews consistently indicated that the residents did not refuse care, and the failures were attributed to staff inaction and inadequate staffing.
Failure to Provide Timely and Appropriate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary treatment, services, and interventions to promote healing and prevent new pressure ulcers for four residents with existing wounds. For one resident with dementia and incontinence, there were repeated delays in implementing wound care orders, with some recommendations not acted upon for several days or even weeks after being made by the wound nurse practitioner. Documentation showed that wound care treatments were not administered as ordered, and inappropriate treatments were continued after being discontinued by the wound care provider. This resident's wounds deteriorated over time, with new ulcers developing and existing ones worsening, ultimately resulting in a hospital transfer for a deteriorating coccyx wound. In addition to delayed wound care, the same resident did not consistently receive timely incontinence care or repositioning every two hours as required by their care plan and facility policy. Certified nursing assistant documentation and interviews confirmed that toileting hygiene and repositioning were frequently missed, with staff citing chronic understaffing as a contributing factor. The resident, who was dependent on staff for mobility and hygiene, did not refuse care, and both staff and the wound nurse practitioner acknowledged that these omissions could contribute to wound deterioration. Observations and interviews also revealed that the resident's support surface (air mattress) was not set according to manufacturer guidelines or the resident's weight, and there was no system in place to monitor or adjust the mattress for residents unable to communicate discomfort. Other residents with pressure ulcers also experienced deficiencies in care. One resident received wound care at an incorrect frequency due to a transcription error, and their air mattress was not set according to their weight, resulting in discomfort. Another resident did not have wound care recommendations implemented in a timely manner, with documentation missing for several days. A fourth resident was using a support surface (air mattress/overlay) without a physician order. These findings were based on observations, record reviews, and staff interviews, all indicating a pattern of failure to provide appropriate pressure ulcer care and prevention.
Failure to Provide Timely and Appropriate Wound and Medication Management
Penalty
Summary
Three residents did not receive treatment and care in accordance with professional standards, their care plans, or their preferences. One resident with diabetes and a history of Foley catheter trauma developed a genital wound that was not treated promptly upon return from the hospital. The facility delayed initiating wound care for over 20 days after becoming aware of the wound, and did not implement the wound NP's recommendations for treatment changes in a timely manner. Documentation shows that the wound worsened and became infected before appropriate interventions were started, and interviews with staff confirmed that treatment orders and recommendations were not implemented as expected. Another resident with diabetes and peripheral vascular disease experienced a delay in receiving a prescribed antibiotic for a skin infection. The facility failed to obtain the medication from the pharmacy in a timely manner and did not notify the provider or document the delay. As a result, the resident's infection worsened and pain increased. The DON confirmed that the process for handling pharmacy delays was not followed, and that required documentation and notifications were missing from the resident's record. A third resident with Alzheimer's disease and severe cognitive impairment did not have weekly documentation of skin conditions as required. Observations revealed multiple skin impairments, including scabs and an open area, that were not documented in the weekly skin assessments or nursing notes. Staff interviews confirmed that these impairments had been present for weeks and should have been included in the assessments, but were not.
Failure to Maintain Homelike and Safe Environment Due to Unaddressed Repairs
Penalty
Summary
Surveyors identified a failure by the facility to maintain a safe, clean, comfortable, and homelike environment for residents, as required by facility policy. Observations across all resident units (A through G) revealed numerous environmental deficiencies, including stained and damaged ceiling tiles, chipped and loose floor tiles, broken blinds, holes and gouges in walls, peeling and missing baseboards, peeling wallpaper, dark substances on ceiling tiles, dried soap streaks on walls, loose ceiling tiles, flickering lights, and missing closet doors. These issues were present in both resident rooms and common areas such as dining spaces and hallways. In several instances, makeshift repairs were observed, such as towels wrapped around leaking pipes and steel wool stuffed into wall holes. Interviews with staff, including a unit manager, the Maintenance Director, and the Administrator, revealed that the process for reporting and addressing maintenance concerns relied on staff writing issues in a work order book on each unit, with the Maintenance Director responsible for daily rounds and repairs. However, review of the work order logs showed that most of the observed deficiencies had not been documented by staff, with only one instance of a broken blind being recorded and not yet addressed. Both the Maintenance Director and Administrator acknowledged that many repairs remained outstanding, particularly in resident rooms, and that staff needed further education on identifying and reporting repair needs. A specific case involved a resident whose heater cover had been broken for over three years and was held together with tape provided by the resident's sister. The resident, who was cognitively intact, reported being told by facility staff that the repair was too expensive and that they should manage the issue themselves. The Maintenance Director confirmed the heater was functional but stated that replacing the cover would require replacing the entire unit, which was considered cost-prohibitive. The Administrator was unaware of the issue and did not consider the taped heater cover an appropriate permanent solution.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to maintain and implement an effective pest control program across all six resident units, as evidenced by daily resident reports of mice sightings and the presence of mice droppings in resident rooms and common areas. Multiple residents, most with intact cognition as indicated by their Brief Interview for Mental Status Score (BIMS), consistently reported seeing mice entering their rooms, particularly from radiators and heaters, both during the day and at night. Surveyors directly observed mice running in hallways and rooms, as well as mice droppings in various locations including closets, bathrooms, storage rooms, and dining areas. Review of facility records and interviews revealed that the pest control company did not provide services as frequently as claimed, with documented visits occurring less often than the weekly schedule stated by facility leadership. The pest control logs did not support the assertion that services were being provided weekly. Additionally, staff interviews indicated ongoing issues with food storage, as many residents kept food in their rooms without using sealed containers, despite education efforts and plans to provide Tupperware that had not yet been distributed. Staff also reported the presence of holes in walls and bathrooms, which were not consistently sealed, providing potential entry points and nesting areas for mice. Housekeeping and maintenance staff acknowledged the persistent mice problem and described expectations for daily cleaning and prompt reporting of pest sightings. However, observations and interviews confirmed that these measures were not effectively preventing or controlling the infestation. The facility's own pest control policy outlined regular inspections, sealing of entry points, proper sanitation, and food storage requirements, but these practices were not fully implemented, as evidenced by ongoing resident complaints, direct observations of pests and droppings, and incomplete follow-through on food storage and structural repairs.
Failure to Provide Required ADL Assistance, Incontinence Care, Showers, and Feeding Support
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for multiple residents who were unable to perform these tasks independently. Specifically, several residents with severe cognitive impairment and total dependence on staff for toileting were not checked or changed for incontinence for extended periods while observed in common areas. Staff interviews confirmed that incontinence care was typically provided only in the morning and afternoon, with no regular checks every 2-3 hours as expected. Care plans for these residents did not include specific toileting schedules or frequency of checks, and staff cited chronic understaffing as a barrier to timely care. Additionally, the facility did not consistently provide scheduled showers to residents who required assistance. Documentation and interviews revealed that some residents had not received showers for several months, despite being scheduled for twice-weekly showers and having no documented refusals. Observations of residents showed signs of poor hygiene, such as significant dry skin and greasy hair, further indicating a lack of regular bathing. Staff and management interviews acknowledged that showers were often missed due to high resident acuity and insufficient staffing, and that refusals were not always documented as required by facility policy. The facility also failed to provide necessary assistance with self-feeding for a resident with severe cognitive impairment and dysphagia. This resident required total or moderate assistance with eating, as documented in care plans and therapy assessments. However, observations showed the resident left alone with meal trays and no staff present to assist, even when the resident was observed coughing during meals. Interviews with nursing, dietary, and rehabilitation staff confirmed that the resident required direct feeding assistance and that staff were expected to be present throughout the meal period, but this was not consistently provided.
Failure to Provide Individualized Activity Program for Residents with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide an adequate activity program for four residents with severe cognitive impairment, as evidenced by direct observations, record reviews, and staff interviews. Each of these residents had documented preferences and care plan interventions for individualized and group activities, including music, sensory stimulation, reading, and religious activities. Despite these documented needs, the activity assistants did not consistently offer or adapt activities to meet the residents' cognitive and physical limitations. Scheduled activities on the calendar were often not conducted as planned, and when activities did occur, residents were either not engaged, not provided with necessary materials, or not given the support required to participate. For example, one resident with dementia and severe cognitive impairment was observed sitting or lying on a couch for extended periods without engagement, despite care plan interventions calling for demonstrations, reminders, and one-on-one activities tailored to their interests. The activity assistant did not approach the resident to encourage participation or provide individualized materials, and group activities were not adapted to the resident's abilities. Similar patterns were observed with other residents, including those who were bedbound or had significant physical limitations, where no bedside or one-on-one activities were provided, and sensory stimulation was absent despite being part of their care plan. Interviews with the Activity Director confirmed that the activity calendar was not being followed and that activity assistants were not effectively engaging residents with lower cognitive abilities. The Activity Director acknowledged that the assistants may not be a good fit for the unit and were not organizing or adapting activities as required for residents with severe cognitive impairment. Throughout the survey period, there was a consistent lack of individualized attention and failure to implement care plan interventions for the affected residents.
Prohibited Space Heater Placed on Trash Can in Resident Room
Penalty
Summary
A deficiency was identified when a resident with dementia and paraplegia, who was dependent on staff for transfers and had moderate cognitive impairment, was found to have a portable space heater in their room. The space heater was placed on top of a trash can with a plastic lid, which contained paper waste. This situation was observed on multiple occasions by the surveyor, with the heater plugged in and producing heat while positioned on the trash can. Facility staff interviews confirmed that the resident's room heating system was not functioning, and a space heater was provided as an interim solution. However, the use of portable space heaters in resident rooms is prohibited by life safety code, and the heater's placement on a trash can with combustible materials further increased the risk of an accident hazard. The maintenance log documented the heating issue, and both the unit manager and maintenance director acknowledged the presence of the space heater and the inappropriate placement, while the administrator stated that residents should not have space heaters in their rooms.
Failure to Maintain Sufficient Staffing and Prevent Staff Sleeping on Duty
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff at all times to meet residents' needs safely and in a manner that promotes their rights and well-being. The facility's own assessment tool outlined specific CNA-to-resident ratios for each shift, but actual staffing schedules frequently fell below these standards. Multiple units were observed to have only one or no CNAs on duty during overnight shifts, despite census numbers that required more staff. Interviews with CNAs, nurses, and residents' proxies revealed that staff shortages led to delays in turning and repositioning residents, missed incontinence care, delayed medication administration, and residents remaining in bed longer than necessary. Some residents requiring two-person assistance for showers went without, and food was often served late or cold due to insufficient staff to assist with feeding. Residents and staff consistently reported that low staffing levels resulted in prolonged call light response times, with some residents waiting up to four hours for assistance during the night. The daily schedule reports confirmed that on several occasions, units operated with staffing ratios significantly below the facility's stated requirements, and in some cases, there was no nurse or CNA present for entire shifts. Staff interviews corroborated that these shortages were ongoing and had a direct impact on the quality and timeliness of care provided to residents, including those with wounds who did not receive necessary repositioning and incontinence care. Additionally, the facility failed to enforce its policy prohibiting staff from sleeping on duty. Surveyors directly observed multiple CNAs sleeping in resident areas during the night shift on three separate units. Residents also reported witnessing staff sleeping and experiencing long wait times for call bell responses at night. Interviews with supervisory staff confirmed that sleeping on duty was an ongoing concern, and disciplinary action had previously been taken against staff caught sleeping. The employee handbook explicitly prohibits sleeping on duty, but this policy was not consistently enforced.
Lack of Documented Wound Care Competency Among Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were trained and demonstrated the necessary competencies and skill sets required to provide wound care, as outlined in the Facility Assessment. The assessment indicated that the facility accepts residents with a broad range of diseases and disabilities, including those requiring complex medical care such as wound care, pressure injury prevention, and skin care. Despite these requirements, a review of staff education files revealed that none of the five licensed nurses reviewed had completed wound care competencies in the past year. During interviews, the DON confirmed that there was no documentation of wound care competencies for the five nurses reviewed, and that only verbal education regarding wound care had been provided, without any assessment of competency. The Administrator also stated that it is expected for nursing staff to demonstrate wound competency, but this expectation was not met. The deficiency was identified through staff interviews, record reviews, and examination of the facility's own assessment and training documentation.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for all five eligible Certified Nurse Aides (CNAs) whose records were reviewed. Documentation showed that four CNAs had not received an annual review for periods ranging from over a year to several years, and one CNA had never received an annual review despite being eligible. During interviews, both the Director of Nursing (DON) and the Administrator confirmed that annual reviews are expected for all staff but were unable to provide reasons for the lack of completed reviews or explain why the process had not been followed.
Medication Error Rate Exceeds Regulatory Limit Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with surveyors observing a rate of 24.14% during medication administration. Three nurses were observed making a total of seven errors out of 29 opportunities, all related to administering medications outside the required one-hour window from the scheduled time. Each of the three residents observed received their prescribed medications late, with delays ranging from one hour and 32 minutes to two hours and three minutes past the scheduled administration times. The medications involved included anticonvulsants, pain medications, supplements, anticoagulants, and anxiolytics, all of which were documented in the residents' physician orders with specific administration times. Interviews with the involved nurses confirmed their awareness that medications should be administered within a one-hour window, and each acknowledged being late in administering the medications. The Director of Nursing also confirmed the facility's policy that medications must be given within one hour of the scheduled time. The facility's own policy on oral medication administration, revised in April 2022, was reviewed and supports this requirement. The observed failures directly resulted in a medication error rate significantly above the regulatory threshold.
Deficiency in Food Palatability and Temperature Control
Penalty
Summary
Surveyors identified a deficiency in the facility's food service, specifically regarding the palatability, temperature, and overall quality of food and drink served to residents. During the initial tour and a resident group meeting, multiple residents voiced dissatisfaction with the temperature and taste of the food, with all residents present at the group meeting stating that the food was not hot. Additional concerns included delays in food delivery, lack of condiments, and the need for residents to obtain their own salt. Direct observations by surveyors across several units revealed that hot foods such as scrambled eggs, potatoes, toast, oatmeal, waffles, and sausage were consistently served warm or lukewarm, rather than hot. Cold items like juice and milk were often only cool, not cold, and in some cases were partially frozen or watery. The texture and taste of the food were also problematic, with reports of bland, overcooked, soggy, or excessively spicy items. The timing of food delivery and the practice of leaving food truck doors open during tray distribution were also noted as contributing factors to the temperature issues. Temperature measurements taken by surveyors confirmed that hot foods were frequently below the expected threshold of 150 degrees Fahrenheit upon arrival to residents, as stated by the Food Service Director. Cold foods were sometimes above or below the recommended temperature of 40 degrees Fahrenheit. The Food Service Director confirmed that food leaves the kitchen at appropriate temperatures but acknowledged the expectation that food should remain at safe and appetizing temperatures when served to residents, which was not consistently achieved.
Failure to Properly Store, Label, and Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, label, and maintain food in accordance with professional standards for food service safety. During multiple observations, surveyors found numerous instances of food items in various refrigerators and kitchenettes that were either undated, unlabeled, uncovered, or improperly stored. Specific findings included open and undated packages of hot dogs, ham, shredded cheese, and whipped cream in the walk-in refrigerator, as well as uncovered Salisbury steaks. Additionally, several types of produce, such as iceberg lettuce, cabbage, celery, carrots, and cherry tomatoes, showed significant signs of decomposition, including discoloration, textural changes, and visible mold growth. The walk-in refrigerator itself had greyish-black wispy growth on the walls, ceiling, and fan cover, and the metal shelving was rusting and flaking, with food stored directly on or below these surfaces. Further observations in unit kitchenettes revealed multiple food items that were undated, unlabeled, uncovered, or stored past their expiration dates. These included cups of coleslaw, containers of food, pre-prepared soup, beverages, and pre-packaged meals that were not kept frozen as instructed. Some containers had crusted substances around their openings, and individual milk containers were found to be expired or bulging. Staff interviews confirmed that all food items should be labeled and dated, and that the presence of mold and flaking metal was not in accordance with facility policy or food safety standards.
Failure to Maintain Accurate and Complete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, resulting in deficiencies related to documentation and adherence to physician orders. For one resident with severe cognitive impairment and a history of stroke, the care plan and physician order required a cervical collar to be worn at all times, with documentation of any refusals and notification to the physician if the collar was not worn. Despite multiple observations by surveyors over several days where the resident was not wearing the cervical collar, the treatment administration record indicated the order was implemented on every shift, and there was no documentation of refusal or physician notification in the medical record. Interviews with staff confirmed that refusals should have been documented and the physician notified, as per the order and facility policy. For another resident with severe cognitive impairment, functional urinary incontinence, and a stage three pressure ulcer, the facility failed to ensure complete documentation of activities of daily living (ADLs) by certified nursing assistants (CNAs). Review of CNA documentation reports for January and February revealed numerous shifts where ADL documentation was missing. Staff interviews confirmed that CNA documentation for ADLs should be completed by the end of each shift, or at the latest, by the next shift. The DON acknowledged that incomplete and inaccurate documentation has been an ongoing issue in the facility. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate. In both cases, the facility did not adhere to its own policy or to physician orders, resulting in incomplete and inaccurate medical records for the residents involved.
Failure to Maintain Resident Dignity and Respect in Care Practices
Penalty
Summary
The facility failed to uphold residents' rights to dignity and self-determination in two key areas. For one resident with prostate cancer, irradiation cystitis, hydronephrosis, and bilateral nephrostomy tubes, surveyors observed on multiple occasions that the resident's nephrostomy urinary drainage bags were left fully visible from the hallway and not placed in privacy bags as required. The resident was cognitively intact and dependent for bed mobility. Interviews with nursing staff and the DON confirmed that drainage bags should have been concealed in privacy bags to maintain the resident's dignity, in accordance with facility policy. Additionally, on two of six units, staff were observed referring to residents as "feeders" within earshot of other residents and speaking in a foreign language in common areas where residents could hear. These actions were witnessed by surveyors on several occasions and were also raised as a concern by residents during a group meeting. The DON confirmed that staff should refer to residents by name and avoid speaking in a foreign language in front of residents.
Failure to Obtain Written Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain written informed consent for the administration of psychotropic medications for two residents. For one resident with severe cognitive impairment and a diagnosis of dementia, ramelteon, a hypnotic medication, was administered following a hospital discharge and readmission to the facility. The medical record did not contain documentation that the resident or their health care proxy was informed of the risks and benefits or provided written consent for the medication. The health care proxy confirmed during an interview that she was not made aware of, nor did she consent to, the administration of ramelteon, and would not have agreed to its use due to concerns about side effects. Facility staff, including the unit manager and DON, acknowledged that written consent was required and could not be found in the record. In a second case, another resident with Alzheimer's disease and severe cognitive impairment was prescribed Depakote, a mood stabilizer, for behavioral discontrol. The resident's medical record did not contain a signed consent form for the use of Depakote from either the resident or their health care proxy. Staff interviews confirmed that only verbal consent had been obtained, and that written consent should have been secured prior to starting the medication. The facility's policy required written informed consent for the administration of psychoactive medications, which was not followed in these instances.
Failure to Assess Resident Before Allowing Self-Administration of Medication
Penalty
Summary
A resident with a diagnosis of acute transverse myelitis and other central nervous system demyelinating disease was admitted to the facility and was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status exam. The resident was observed with a cup containing five tablets, including renal-vite, sevelamer carbonate, and Tylenol extra strength, left on their lunch tray for self-administration after returning from dialysis. The resident reported that the nurse had left the medication for them to take on their own. Review of the medical record showed that there was no care plan or assessment completed for the resident to self-administer medication. Facility policy required all drugs to be stored safely and securely, and staff interviews confirmed that medications should not be left at the bedside unless a resident has been assessed and care planned for self-administration. Both the nurse and the DON stated that nurses are expected to remain with residents during medication administration and not leave medications unattended.
Failure to Ensure Resident Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by policy and regulation. A resident with Alzheimer's Disease and severe cognitive impairment, who was dependent on staff for all care, was observed with a pillow placed under the fitted sheet on the left side of the bed, which was not touching the resident. The bed was also positioned slanted to the left and close to the wall, rather than centered in the room. Staff interviews revealed that the pillow was used to prevent the resident from rolling or sliding out of bed, rather than for comfort or positioning, and there was no documentation of a restraint assessment or a physician's order for the use of a restraint. Further interviews with nursing staff and the DON indicated a lack of clarity regarding the purpose of the pillow and the bed's placement. The care plan referenced the use of pillows and positioning devices for comfort, but the observed use and staff explanations did not align with this intervention. The facility's policy requires a pre-restraint assessment, exploration of alternatives, and a physician's order with consent prior to restraint use, none of which were documented or followed in this case.
Inaccurate MDS Coding for Contractures and Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, resulting in inaccurate documentation of their clinical status. For one resident with Alzheimer's Disease and severe cognitive impairment, the MDS assessment did not reflect the presence of bilateral upper and lower extremity contractures, despite observations and staff interviews confirming these contractures had been present for over a year. The MDS nurse acknowledged the inaccuracy in the assessment. For another resident with anemia and age-related cognitive decline, the MDS assessment failed to document a fall that occurred between assessment periods. Nursing progress notes and an incident report confirmed the resident had an unwitnessed fall from bed, but this event was not captured in the subsequent MDS. The MDS nurse and the Director of Nursing both confirmed that the fall should have been coded according to Resident Assessment Instrument (RAI) guidelines, but was omitted.
Failure to Follow Physician Orders for Weights and Equipment
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for two residents. For one resident with a history of diabetes and congestive heart failure, physician's orders required daily weights and notification of the physician if the resident's weight increased by 2 pounds or more within 1-2 days. However, the electronic medical record and medication administration record showed that daily weights were not consistently obtained over several days, with some days marked as 'sleeping,' 'refused,' or with no entry at all. There was no documentation that the physician was notified about the missed weights or refusals, as required by the facility's policy and the physician's orders. Interviews with nursing staff and the DON confirmed that daily weights should be completed as ordered and that refusals or missed weights should be communicated to the physician. For another resident with acute transverse myelitis, paraplegia, diabetes, and a stage 3 pressure ulcer, the resident was observed using an air mattress. However, there was no physician's order for the air mattress, nor was it included in the resident's active plan of care. Staff interviews confirmed that a physician's order is expected for the use of an air mattress to ensure appropriate settings based on the resident's mobility and weight. The DON also stated that a physician's order should be present for such equipment.
Failure to Address and Treat Decline in Self-Feeding Ability
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain a resident's ability to perform activities of daily living, specifically self-feeding, after a hospitalization. The resident, who had a history of dementia and functional urinary incontinence, was able to feed independently with set-up assistance prior to a hospital admission for Clostridium difficile infection. Upon return from the hospital, the resident was noted by both the health care proxy and certified nursing assistant to have lost the ability to self-feed and became totally dependent on staff for eating. Despite this significant decline, the facility did not initiate or document any assessment or intervention to address the loss of self-feeding ability. The speech therapy evaluation conducted after the resident's return from the hospital identified total dependence in self-feeding but did not include a referral for further assessment or therapy, nor was a rationale for this omission documented. The Director of Rehab confirmed that no referral was made to occupational therapy, and the resident was not evaluated or treated for self-feeding decline by any therapy discipline during this period. Nursing and therapy staff interviews revealed a lack of awareness or action regarding the resident's change in functional status. The Director of Nursing stated that therapy should have evaluated the decline in self-feeding and documented their findings, but this did not occur. Documentation from the period following the resident's return from the hospital consistently indicated dependence on staff for feeding, with no evidence of interventions or assessments to address or potentially restore the resident's previous level of independence.
Failure to Implement Physician-Ordered Orthosis for Resident with Hand Contracture
Penalty
Summary
The facility failed to provide range of motion (ROM) care and treatment in accordance with professional standards for one resident with a right hand contracture. Despite a physician's order and care plan directing staff to apply a carrot orthosis to the resident's right hand daily and remove it at bedtime, multiple observations over several days showed the resident without the orthosis. Instead, the resident was seen with a napkin or silver wrapper in the affected hand, and staff reported substituting a washcloth when the orthosis was unavailable. The resident stated that staff did not assist with applying the orthosis and that it was sometimes missing due to theft by other residents. Review of the medical record revealed no documentation explaining the absence of the orthosis or any changes to the physician's order or care plan. Interviews with staff, including a CNA, nurse, unit manager, and DON, confirmed awareness of the order for the orthosis but indicated a lack of follow-up to replace the missing device or update documentation. There was no evidence that the therapy department was notified to obtain a new orthosis, nor was there documentation of resident refusal or rationale for not following the prescribed care.
Failure to Obtain Weekly Weights for Resident with Recent Weight Loss
Penalty
Summary
The facility failed to obtain weekly weights for a resident with a recent history of weight loss, as required by both facility policy and physician orders. The resident, who has dementia and severe cognitive impairment, was dependent on staff for all self-care tasks. The resident experienced a weight loss of 7.47% over three months, prompting a physician order for weekly weights starting on 2/14/25. However, the weight log showed that weights were not recorded on 2/14/25, 2/21/25, and 3/7/25, and the Treatment Administration Record did not indicate that a weight was obtained on 3/1/25 as specifically ordered. Interviews with facility staff, including a unit manager and the Director of Nursing, confirmed that the weekly weights were not obtained as ordered and that the unit manager was unaware of the order. The resident's nutritional care plan required weights to be taken as indicated and for significant changes to be reported to the dietitian and physician, but there was no documentation that these interventions were followed. All available records and risk meeting notes lacked evidence that the required weights were obtained.
Failure to Provide Required Dental Services
Penalty
Summary
The facility failed to provide dental services to a resident who was admitted with diagnoses of dementia and depression. Despite the resident scoring 14 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition, and reporting during an interview that their teeth were broken and needed to be fixed, there was no documentation in the medical record or consents indicating that the resident had been seen by a dentist or had signed a consent form for dental services. Medical Records staff confirmed that the resident had not been seen by the in-house dentist and could not provide evidence of an external dental visit. As a result, the facility did not provide the required dental care for this resident.
Failure to Report Change in Director of Nursing to State Agency
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the Director of Nursing (DON) position. During an interview, the Administrator confirmed that there was a recent change in the DON, with the new DON starting in October 2024. However, a review of the Health Care Facility Reporting System (HCFRS) showed that the facility did not submit the required notice of this change. The Administrator acknowledged that the change in DON was not reported to the state agency as required.
Incomplete CNA Documentation in Resident ADL Flow Sheets
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as required by their own policies. The deficiency was identified through a review of the Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets, which were found to be inconsistently completed or left blank for significant periods. For Resident #1, admitted in December 2023 with multiple diagnoses including type 2 diabetes mellitus and dysphagia, the ADL Flow Sheets were incomplete for numerous shifts across December 2024. Similarly, Resident #2, admitted in September 2019 with major depressive disorder, and Resident #3, admitted in April 2021 with mild cognitive impairment, also had significant gaps in their ADL documentation for January 2025. Interviews with CNAs revealed that documentation was often not completed due to time constraints and busy shifts, with some CNAs admitting to documenting care on subsequent days. The Unit Manager and Director of Nursing (DON) were unaware of the incomplete documentation, although the facility's policy requires CNAs to complete documentation by the end of each shift. The lack of awareness and oversight contributed to the deficiency, as the facility's policy was not enforced, resulting in incomplete medical records for the residents involved.
Incomplete Documentation During Medical Emergency
Penalty
Summary
The Facility failed to maintain a complete and accurate medical record for a resident who experienced a medical emergency. The deficiency occurred when Unit Manager #1 did not document the presence of food in the resident's mouth after the resident was found without respirations. The facility's policy required documentation of significant changes in a resident's condition, but this was not adhered to in this instance. The resident involved had multiple diagnoses, including amyloidosis, dementia, neuropathy, fibromyalgia, and dysphagia. During the incident, the resident was found unresponsive with food in their mouth, and CPR was initiated. However, the Unit Manager did not document the presence of the food, which was a significant detail related to the resident's condition at the time of the emergency. The Director of Nurses confirmed that the documentation should have included this information.
Failure to Provide Scheduled Dialysis Leads to Hospital Transfer
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards for a resident with end-stage renal disease (ESRD). The resident, who had a physician's order for hemodialysis three times a week, did not receive dialysis as scheduled. The facility's policy required that residents with ESRD receive dialysis treatment from a dialysis facility. However, on a scheduled dialysis day, the facility's dialysis center was closed, and the resident missed their treatment. The resident was supposed to receive dialysis the following day, but due to a miscommunication, the resident missed dialysis again and was transferred to the hospital emergency department. The resident, who had been admitted to the facility in December 2017 with diagnoses including diabetes, ESRD, and dementia, experienced mental status changes due to the missed dialysis treatments. Interviews with facility staff revealed a breakdown in communication regarding the change in the dialysis schedule. The unit manager was informed of the schedule change and expected the nursing staff to pass on the information, but this did not occur effectively. As a result, the resident was not on the dialysis schedule for the rescheduled day, leading to the need for hospital transfer.
Deficiencies in Medical Record Documentation
Penalty
Summary
The Facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in documentation. For one resident, there was no documentation of a physician's order to transport them to the Hospital Emergency Department on a specific date, despite the facility's policy requiring such documentation. The resident, who had been admitted to the facility since December 2017, had diagnoses including diabetes, end-stage renal disease (ESRD), and dementia. The absence of a documented physician's order was confirmed during an interview with the Regional Nurse Consultant. For another resident, the Facility did not consistently document weekly skin assessments as required by their policy. This resident, admitted in April 2019, had diagnoses including ESRD, Parkinsonism, and cerebral palsy. Although the Treatment Administration Records indicated that weekly skin checks were conducted, there was no supporting documentation in the medical record for several specified dates. The Regional Nurse Consultant confirmed that the nursing staff failed to document these assessments using the facility's electronic skin observation tool.
Failure to Notify Physicians of Omitted Medications
Penalty
Summary
The facility failed to ensure that nursing staff notified attending physicians of omitted medication doses for 13 out of 22 sampled residents during a specific shift. The omission occurred on the 7:00 A.M. to 3:00 P.M. shift, where multiple medications were not administered to residents. The facility's policy requires that any changes in a resident's medical condition, including medication errors, be reported to the attending physician, but this was not adhered to. The report details the specific medications omitted for each resident, which included critical medications such as antihypertensives, anticoagulants, insulin, and antidepressants. The medical records reviewed did not contain documentation indicating that the attending physicians were informed of these omissions. This lack of communication could potentially impact the residents' health, as these medications are essential for managing their conditions. Interviews with facility staff revealed that the Unit Manager on duty during the shift was unable to administer all medications due to being the only nurse available. Despite being aware of the missed medications, neither the Unit Manager nor other staff members reported the omissions to the residents' physicians. The Regional Nurse confirmed that the expectation was for nursing staff to report such omissions in accordance with federal regulations and facility policy.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that 13 out of 22 sampled residents were free from significant medication errors. On a specific day, several critical medications, including insulin, antihypertensives, and anticoagulants, were not administered to these residents during the 7:00 A.M. to 3:00 P.M. shift. The facility's policies on medication monitoring and oral medication administration require that medications be administered as per prescriber orders and documented accordingly, which was not adhered to in this instance. The Medication Administration Records (MAR) revealed that multiple doses of various medications were omitted for the affected residents. These medications included, but were not limited to, Metoprolol, Xarelto, Amiodarone, Humalog, and Lidocaine patches. The omissions were not documented, and there was no evidence that the attending physicians were notified or that new orders were obtained for the missed doses. Interviews with facility staff indicated that on the day of the incident, a unit manager was the only nurse available on the Beechwood Unit and was unable to administer all the required medications. This staffing issue led to the omission of medication doses, which put residents at risk for potential negative outcomes. The regional nurse confirmed that nursing staff are expected to report omitted doses to physicians, as per federal regulations and facility policy, which was not done in this case.
Failure to Prevent Abuse and Restraint of Resident
Penalty
Summary
The facility failed to prevent abuse for a resident who was physically restrained to a chair by a staff member, causing emotional distress and weepiness. The resident, who was admitted with diagnoses including dementia and anxiety, was found by a nurse from a different department crying and restrained by their clothing to a chair in the common area. The resident's shirt was pulled over the back of the chair and tucked under, preventing them from rising. The resident was severely cognitively impaired and required supervision with mobility, making it unlikely that they could have restrained themselves in this manner. The Director of Nursing was informed of the incident and conducted interviews with the certified nursing aide and nurse on the unit, but neither admitted to restraining the resident. The Director of Nursing confirmed that the resident could not have tucked their shirt behind themselves in the chair. The incident was reported to the resident's family and the police, and the involved employees were terminated. The facility's policy on abuse prohibition was reviewed, which includes prevention, identification, investigation, protection, and reporting of abuse incidents.
Failure to Prevent Physical Restraint of Resident
Penalty
Summary
The facility failed to prevent a resident from being physically restrained. Resident #157, who has dementia and anxiety and is severely cognitively impaired, was found restrained to a chair by their clothing. The incident was discovered by a nurse from a different department who found the resident crying with their shirt pulled over the back of the chair and tucked under, preventing them from rising. The Director of Nursing confirmed that the resident could not have restrained themselves in this manner. The Director of Nursing interviewed the certified nursing aide and nurse on duty, but neither admitted to restraining the resident. The incident was reported to the resident's family and the police, and the involved employees were terminated. The facility's policy clearly states that patients have the right to be free from physical restraints unless required for medical treatment, which was not the case for Resident #157.
Failure to Transcribe Physician's Orders and Implement 24-Hour Chart Check Policy
Penalty
Summary
The facility failed to meet professional standards of quality for four residents by not accurately transcribing physician's orders and not implementing the 24-hour chart check policy. For Resident #17, the facility did not correctly transcribe a physician's order for Dymista Nasal Suspension, and the error was not caught during the 24-hour chart check. Similarly, for Resident #33, a physician's order for Metformin was incorrectly transcribed, and the error was not identified during the 24-hour chart checks performed on subsequent days. Both residents had their orders inaccurately recorded, which was confirmed through interviews with nursing staff and the Director of Nursing (DON). The DON acknowledged that the transcription errors should have been corrected during the 24-hour chart checks but were not. For Resident #164, the facility failed to obtain a physician's order for the use of a suction machine, despite the resident having frequent episodes requiring suctioning due to secretions. Observations revealed that the suction machine was in use without a proper order, and the DON was unaware of its necessity. The resident had been suctioned multiple times since January without an official order, as confirmed by progress notes and staff interviews. The Unit Manager and DON both acknowledged the need for a physician's order for the suction machine. For Resident #434, the facility did not obtain daily weights as ordered by the physician. The resident, who had diagnoses including chronic diastolic congestive heart failure and dependence on renal dialysis, had missing weight documentation on two consecutive days. The failure to document and report the missing weights to the Nurse Practitioner was confirmed through record reviews and staff interviews. The DON confirmed that daily weights should be completed as ordered and any refusals should be documented and reported to the physician.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards of practice for four residents. For Resident #133, the facility did not develop and maintain a plan for the care of the nebulizer machine, mask, and tubing. Observations showed the nebulizer mask uncovered and resting on items in the bedside table drawer, and there was no physician's order or care plan for the nebulizer machine's maintenance. Nurse #16 confirmed that the mask should be changed weekly and covered to prevent contamination. For Resident #36, the facility did not develop and maintain a plan for the care of the CPAP machine, including the mask and tubing. The CPAP mask was observed uncovered and hanging off the bedside table, and the machine contained water. There were no interventions for the care of the CPAP machine in the current physician's orders and care plans. Nurse #16 indicated that the CPAP mask should be covered when not in use. Residents #95 and #163 had issues with the timely changing of oxygen tubing per physician's orders. Resident #95's nasal cannula tubing was dated 2/14/24, despite orders to change it weekly. Similarly, Resident #163's nasal cannula tubing was dated 2/27/24, although it was supposed to be changed every Thursday. Both the nurse and the DON confirmed that they would expect the oxygen tubing to be changed weekly as ordered.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5%, with 3 out of 4 nurses observed making 5 errors out of 25 opportunities, resulting in a medication error rate of 20%. These errors impacted three residents. For Resident #69, the nurse administered the wrong multiple vitamin. For Resident #19, the nurse administered Risperdal 1 hour and 48 minutes after the scheduled time. For Resident #17, the nurse administered Lactaid without a meal, the incorrect form of guaifenesin, and an undated inhaler. The facility's policy on medication administration was not followed in these instances. The errors included administering the wrong form of a medication, administering medications late, and failing to check expiration dates. Interviews with the nurses and the Director of Nursing confirmed these lapses in following the facility's medication administration policy. The deficiencies were observed during a survey conducted on 3/19/24 and 3/20/24.
Failure to Secure Medications and Biologicals
Penalty
Summary
The facility failed to ensure that medications and biologicals were appropriately stored in locked compartments and not accessible to unauthorized individuals. Multiple medications and biologicals were observed left unlocked at the residents' bedside on two of six resident units. Specifically, five residents had various medications such as caffeine pills, multivitamins, saline nasal spray, neosporin, dry mouth spray, antifungal powder, lotion, and a handheld inhaler left unsecured. Some of these residents were cognitively intact, while others had moderate cognitive impairment or were not assessed for self-administration of medications. Interviews with nursing staff and unit managers confirmed that these medications should not have been left unlocked at the bedside, even if residents were able to self-administer them. The facility also failed to ensure that the medication cart on one of six units had dated medication when opened and properly stored topical medications separately from oral medications. During an inspection of the medication cart, an opened and undated bottle of atropine sulfate ophthalmic eye drops was found, making it impossible to determine the expiration date. Additionally, clotrimazole topical cream was stored with oral medications. Interviews with nursing staff and the Director of Nursing confirmed that eye drops should be dated when opened and discarded after 28 days, and topical ointments should be kept separately in the treatment cart. Furthermore, the facility failed to ensure that one of six medication rooms was locked and secured. The A unit medication room was observed to be unlocked and unsupervised on multiple occasions. Interviews with nursing staff and the unit manager confirmed that the medication room should always be locked. These lapses in medication storage and security practices indicate a failure to adhere to the facility's policy on the storage and expiration dating of medications and biologicals, potentially compromising resident safety.
Failure to Promote Dignity and Privacy for Residents
Penalty
Summary
The facility failed to ensure that care was provided in a manner that promoted dignity and enhanced the quality of life for three residents. Specifically, Resident #130 was observed multiple times eating with his/her hands and having food substances like syrup and milk on his/her hands without staff intervention to assist or maintain dignity. Similarly, Resident #132 and Resident #14 were also observed eating with their hands in the dining room without staff assistance, despite staff being present. Unit Manager #1 acknowledged that residents should not be eating with their hands unless provided with finger foods and that staff should offer assistance or alternative food options if residents are unable to use utensils. Additionally, the facility failed to provide privacy for Resident #132's Foley catheter bag. The Foley bag was observed hanging from the side of the bed with urine in it and without a privacy bag on multiple occasions, making it visible to staff and the resident's roommate. CNA #3 confirmed that Foley bags should have privacy covers but noted that the night shift staff often did not put them on, and he had not had time to address it. Unit Manager #1 also confirmed that privacy bags should be used to cover Foley bags for privacy and dignity.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was informed and provided consent for the administration of psychotropic medications. Resident #156, who was admitted in April 2022 with a diagnosis of dementia and had a health care proxy activated on 10/17/22, was receiving Trazodone and Zoloft. The review of the psychotropic medication consent forms indicated that consents for Trazodone, Ativan, and Zoloft were not signed by either a facility representative or a resident representative. This indicates a failure to follow the facility's policy on informing residents or their representatives about the initiation, reason for use, and risks associated with psychotropic medications. During interviews, the Unit Manager mentioned attempts to reach the healthcare proxy to sign the consents but admitted that the consents had not been mailed and staff waited for the representative to come to the facility. The Director of Nursing stated that she would not administer medication without a signed consent and would fax or mail the consents if the family could not be reached. Despite these statements, the necessary consents were not obtained, leading to the deficiency noted in the report.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer medications. Specifically, a nurse left medications unattended with the resident to self-administer without a physician's order and an assessment for self-administration completed. The facility's policy requires that patients who request to self-administer medications be evaluated for safe and clinically appropriate capability, and a physician/advanced practice provider (APP) order is required. Additionally, the evaluation of capability must be performed initially, quarterly, and with any significant change in condition. However, the resident's medical record did not indicate any assessment for self-administration of medication, nor was there an active physician's order for self-administration. The surveyor observed the resident with a medication cup containing pills on two separate occasions, with no nurse present in the room or hallway. The resident confirmed that the nurse usually leaves the pills for self-administration. During interviews, Nurse #1 admitted to sometimes leaving medications unattended with the resident and was unaware of the policy. The Unit Manager and the Director of Nursing (DON) confirmed that nurses must stay with residents while they take their medications unless they are assessed for self-administration. The DON acknowledged that the resident had not been assessed for self-administration of medication.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents. For Resident #164, who was admitted with diagnoses including dysphagia and dementia, the facility did not create a care plan for the use of a suction machine. Observations on multiple occasions revealed that the suction machine was present in the resident's room with yellowish/red fluid in the cannister and the tubing hanging unbagged, directly touching the nightstand. Despite progress notes indicating the need for suctioning since January, the Director of Nursing was unaware of the situation and confirmed that there should have been a care plan in place for the suction machine's use. For Resident #2, who was admitted with diagnoses including muscle weakness, primary osteoarthritis, and chronic pain syndrome, the facility failed to ensure the application of braces as indicated in the resident's plan of care. Multiple observations showed that the resident was not wearing the prescribed braces on either arm, despite physician's orders and a care plan specifying their use. The resident confirmed that staff did not check to ensure the braces were worn, and the Director of Nursing acknowledged that the braces should have been applied as ordered.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for Resident #130, who has a diagnosis of dementia and severe cognitive impairment. The resident's care plan and Kardex indicated that they required limited assistance with cueing for eating. However, during multiple observations, the resident was seen eating with their hands, dropping food on themselves and the floor, and struggling to use utensils without receiving the required assistance from the staff. CNA #1 was observed setting up the resident's meal tray but leaving the room without providing the necessary cueing or assistance, resulting in the resident eating with their hands and making a mess. Interviews with CNA #1 and Unit Manager #1 revealed that the staff were aware of the resident's decline in eating abilities over the past month but did not provide the required assistance as outlined in the care plan. CNA #1 misunderstood the care instructions, believing that setting up the meal tray was sufficient, while the Unit Manager acknowledged that the resident needed verbal cueing and assistance with eating. Despite this knowledge, the staff failed to provide the necessary support, leading to the resident's continued difficulty and messiness during meals.
Failure to Identify and Document Resident's Skin Bruises
Penalty
Summary
The facility failed to ensure quality of care that met professional standards of practice when a resident sustained two purple and blue areas on their left arm, which were not identified by staff performing daily care nor by nursing staff performing weekly skin checks. The resident, who had intact cognition and was dependent on staff for showering and bathing, mentioned that they might have bumped their arm on the door but did not inform the nurses. Despite a physician's order for weekly head-to-toe skin assessments and a care plan that included observing skin condition daily and reporting abnormalities, the bruises were not documented in the resident's medical record or identified during skin checks conducted on multiple dates in February and March 2024. Additionally, the resident had a care plan focus on the risk of injury related to anticoagulant therapy, which included observing for bruising, but this was also not followed. Nurse #10 confirmed that the bruises had been present for about two weeks and should have been identified by staff and documented in the skin checks. The nurse also mentioned that an incident report should be completed for new skin injuries, and the doctor and responsible family should be notified, which did not occur in this case.
Failure to Identify and Prevent Decrease in Range of Motion
Penalty
Summary
The facility failed to identify and prevent a decrease in range of motion (ROM) for a resident, leading to a deficiency. Resident #48, who was admitted with diagnoses including anemia, heart failure, thyroid disorder, and osteoarthritis of the left shoulder, was observed to have a significant decrease in ROM in the left hand. Despite being cognitively intact and having no functional impairment in ROM as per the most recent Minimum Data Set (MDS), the resident's left hand was observed to be contracted, with the fourth and fifth fingers flexed nearly touching the palm. The resident reported being unable to straighten the fingers for months and had informed a CNA, who did not escalate the concern to nursing or rehabilitation services, assuming it was due to arthritis and not something that could be fixed. Further observations and interviews revealed that the nursing and rehabilitation staff were unaware of the resident's ROM issues. The CNA admitted to not reporting the concern, and the nurse who had cared for the resident for five years also did not notice the change in ROM. The resident's medical records and progress notes failed to indicate any decrease in ROM, and the quarterly rehabilitation screen did not specifically address ROM. It was only after the surveyor's observation and subsequent interviews that an order was placed for an occupational therapy evaluation, which confirmed the resident's ROM deficit and recommended interventions to prevent further contractures. The deficiency was further highlighted by the lack of communication and proper documentation among the staff. The unit manager and rehabilitation services staff were not aware of the resident's ROM issues, and the quarterly rehabilitation screen did not identify the problem. The occupational therapy evaluation eventually recommended the use of finger separators and a resting hand splint to prevent further contractures, but this intervention came only after the surveyor's findings and not as a result of the facility's routine monitoring and care processes.
Failure to Properly Label Enteral Feeding Bags
Penalty
Summary
The facility failed to provide care according to professional standards of practice for a resident with a gastrostomy tube (g-tube). Resident #136, who was moderately cognitively impaired and had a g-tube, was observed multiple times with an unlabeled bag of enteral feed. The bag did not indicate the name of the resident, the date and time it was hung, or the name of the nurse who hung the bag. This made it impossible to determine when the bag was hung and whether it was within the safe usage period as per the manufacturer's instructions. The surveyor observed the unlabeled bag on three separate occasions, and during an interview, a nurse confirmed that the bag should have been labeled with the necessary information. The Director of Nursing also confirmed that the enteral feeding should be labeled, dated, and initialed by the nurse hanging the feeding. The facility's failure to label the enteral feeding bags properly led to a deficiency in the care provided to Resident #136.
Failure to Provide Emergency Smooth Clamps for Dialysis Patients
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for four residents who required renal dialysis. Specifically, the facility did not ensure that emergency smooth clamps were kept with the residents for emergencies related to a hemodialysis catheter. The facility's policy required that smooth edge clamps be maintained with the patient at all times, including at the bedside, on the patient's clothing during transport, and attached to the patient's clothing if the patient is mobile. However, observations and interviews revealed that these clamps were not present as required for the residents in question. Resident #49, who was admitted with end-stage renal disease and dependence on renal dialysis, was observed multiple times without the required emergency smooth clamps on their wheelchair or bedside. Similarly, Resident #434, who was also dependent on renal dialysis, was observed without the emergency smooth clamps in their room on several occasions. Both the nurse and the Director of Nursing confirmed that the clamps should have been present in the residents' rooms or on their wheelchairs. Resident #36, with moderately impaired cognition and dependence on renal dialysis, was also found without the required smooth clamps in their room or on their wheelchair. Despite the care plan indicating the need for these clamps, they were not observed during multiple checks. Resident #105, who had moderately impaired cognition and a hemodialysis catheter, was similarly found without the smooth clamps in their area. The Unit Manager mentioned that clamps were not sent with residents to dialysis because the dialysis den had a supply, but this did not align with the facility's policy.
Failure to Ensure Availability of Routine Medication
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of Resident #17, who was admitted with diagnoses including chronic obstructive pulmonary disease, allergic rhinitis, and overactive bladder. The resident had a physician's order for Myrbetriq, a medication used to treat an overactive bladder, which was not administered on multiple occasions in March 2024. Specifically, the medication was not given on 3/12/24, 3/14/24, 3/15/24, 3/16/24, and 3/20/24 due to it being unavailable. The facility's policy indicated that staff should immediately take action to obtain the medication from the pharmacy upon discovering a shortage, but this was not effectively carried out. Nurse #3 and Nurse #8 both confirmed that the Myrbetriq had not been available for several days, with Nurse #8 noting that the pharmacy had indicated the medication would not be sent without an override request and payment authorization from the facility. Despite this, the necessary steps to obtain the medication were not taken, and the Director of Nursing (DON) was not made aware of the issue until 3/20/24. The DON acknowledged that the medication should have been available, indicating a lapse in communication and follow-through in ensuring the resident's pharmaceutical needs were met.
Failure to Complete Required AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications for two residents. Specifically, the facility did not complete the Abnormal Involuntary Movement Scale (AIMS) assessments as required for residents receiving antipsychotic medications. For Resident #2, who was admitted with diagnoses including major depressive disorder, post-traumatic stress disorder, and anxiety disorder, the most recent AIMS assessment was completed on 1/21/22, despite the resident receiving antipsychotic medication Seroquel. The facility policy mandates that AIMS assessments be completed every six months, but this was not adhered to for Resident #2, as confirmed by the Unit Manager and the Director of Nursing (DON). Resident #2's care plan indicated a risk for complications related to psychotropic drugs, yet the necessary assessments were not conducted in a timely manner. Similarly, Resident #33, admitted with diagnoses including schizophrenia, schizoaffective disorder, and major depressive disorder, did not have an AIMS assessment completed within the required timeframe. The most recent AIMS assessment for Resident #33 was completed on 12/27/22, despite the resident receiving antipsychotic medications Ziprasidone and Perphenazine. The Behavioral Health note dated 3/8/24 indicated that a new AIMS assessment was overdue. The DON confirmed that AIMS assessments should be completed every six months for residents on antipsychotic medications, but this was not done for Resident #33. Both residents' care plans indicated a risk for complications related to psychotropic drugs, highlighting the facility's failure to adhere to its own policies and ensure proper monitoring of residents on antipsychotic medications.
What surveyors are citing around you — mapped
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Medford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medford Rehabilitation And Nursing Center | 0.6 mi | — | 0 | 0 |
| Regalcare At Glen Ridge | 1.1 mi | — | 35 | 0 |
| Life Care Center Of Stoneham | 1.9 mi | — | 15 | 0 |
| Dexter House Healthcare | 2.3 mi | — | 16 | 0 |
| Winchester Rehabilitation And Nursing Center | 2.6 mi | — | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.