Country Gardens: Medical Records Left Unsecured - MA
Federal inspectors found Country Gardens Health and Rehabilitation Center repeatedly failed to secure private health information during a July 2024 inspection. The violations occurred in two rooms on the facility's main hallway, both accessible to anyone walking by.
On June 26 at 4:24 PM, an inspector observed the copy room door open and unattended. Two boxes labeled "medical records" were visible from the hallway, along with physician notes on the fax machine that included medical diagnoses and resident face sheets. The boxes contained hospital discharge summaries and resident diagnoses.
The Administrator told the inspector that doctors and nurse practitioners fax their notes to that machine, and the medical records were waiting to be filed. The door "should be locked to protect resident information because it is accessible to anyone walking by," the Administrator said.
Twenty-seven minutes later, the inspector returned to find the same scene: copy room door open, medical records visible, fax machine loaded with private health information.
The Chief Nursing Officer acknowledged the door "should have been closed and locked because the room contains residents' personal medical information but it was not."
The Staff Development Coordinator's office presented an even more extensive breach. On June 27 at 8:19 AM, the inspector found the office door "wide open with no staff inside." Two large piles of physician orders covered a table, containing residents' names, dates of birth, allergies, diagnoses, diet orders, treatment orders, and medication orders.
A large box held three binders with resident-specific information including Kardex cards identifying residents and their care needs, daily living flow sheets with bowel and bladder information, and daily census listings. A purple binder labeled "Infection Control Line Listings for 2024" contained pages of resident names, infections, signs and symptoms experienced by residents, and treatments.
The Director of Nursing said the office "should be closed at all times when no one is in the office."
But the violations continued. On July 1, inspectors found the same office door wide open and unattended at 8:02 AM, 9:13 AM, and 9:22 AM. Each time, the same two piles of physician orders with private health information remained spread across the table.
The Chief Nursing Officer repeated that the door "should never be left open and unattended because there are resident records in there and accessible to anyone."
The facility's own policy, revised March 4, 2024, stated that "medical records shall not be left in open areas where unauthorized persons could access identifiable resident information."
Beyond privacy failures, inspectors documented systematic breakdowns in resident care planning and medical oversight. Nine residents lacked proper care plans for critical conditions and treatments. The facility failed to develop care plans for diabetes management, heart infection treatment requiring IV antibiotics, blood-thinning medications, and elopement risk.
One resident with moderate cognitive impairment received four different diabetes medications including insulin injections, but had no care plan addressing the diagnosis, treatment, or monitoring requirements. Staff performed 184 fingerstick blood sugar tests over three months without physician orders to do so.
Another resident arrived with a serious heart infection requiring IV antibiotics through a PICC line — a catheter threaded into a major vein near the heart. The facility never developed a care plan for this complex treatment, despite physician orders for weekly dressing changes and catheter measurements.
A resident with bipolar disorder had the diagnosis documented in multiple psychiatric evaluations and treatment notes, but facility assessment forms consistently omitted it from three separate evaluations over four months.
Professional nursing standards also broke down. Staff failed to notify physicians when a COPD patient's oxygen levels consistently exceeded the prescribed range of 88-92 percent. The resident's oxygen saturation readings climbed as high as 99 percent on multiple occasions, but no one contacted the doctor to reassess the treatment plan.
"The Physician should be notified if the oxygen therapy regimen is not producing the intended outcome," one nurse told inspectors.
When a resident with dementia fell in a bathroom and hit his head, a nursing assistant moved him off the floor and into a wheelchair before any nurse assessed him. The facility's own policy required immediate physical assessment for unwitnessed falls with head injuries.
The Director of Nursing said the assistant "should not have moved the Resident after finding him on the floor after having a fall. She should have notified the Nurse right away so she could assess the Resident."
Activity programming essentially disappeared from one entire unit. The Activity Director explained that staff kept pulling activity assistants to work as nursing aides, "so they stopped sending Activity Assistants to that unit." Residents sat in the dayroom with no organized activities, materials, or staff supervision for hours at a time.
The facility operated without a qualified activities director for nearly a year. The previous director was terminated in July 2023, and the current director lacks the required credentials — either as a therapeutic recreation specialist, activities professional with two years experience, or occupational therapist.
One resident endured a medication mix-up that left him without prescribed anti-anxiety medication for 10 days. A psychiatric consultant recommended discontinuing one Klonopin order, but staff discontinued the wrong one. The facility never notified the physician about the error.
Another resident had four surgical drains in his rectum following treatment for a severe abscess, but the facility had no physician orders for monitoring or care of the devices. Medical literature indicates these drains require specific cleaning instructions and monitoring for complications including infection and bleeding.
The pattern extended to basic documentation requirements. A resident receiving IV antibiotics for a wound infection should have had weekly comprehensive skin assessments with wound measurements, but staff failed to document the size or detailed description of open areas.
Staff repeatedly violated their own policies while administrators acknowledged the failures. The Chief Nursing Officer confirmed that doors containing medical records "should never be left open," that residents on blood thinners "should have a care plan," and that those assessed as elopement risks need comprehensive care planning.
The inspection revealed a facility where basic privacy protections, care planning, and clinical oversight had broken down across multiple departments, leaving vulnerable residents without proper safeguards or treatment protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Gardens Health and Rehabilitation Center from 2024-07-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
COUNTRY GARDENS HEALTH AND REHABILITATION CENTER in SWANSEA, MA was cited for violations during a health inspection on July 1, 2024.
Federal inspectors found Country Gardens Health and Rehabilitation Center repeatedly failed to secure private health information during a July 2024 inspection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.