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Melrose Healthcare: Wounds, Pacemaker Gaps - MA
The resident was unable to walk and depended entirely on staff for turning in bed, hygiene, and transfers....
Latest reports, citations, and penalties from CMS data
The resident was unable to walk and depended entirely on staff for turning in bed, hygiene, and transfers....
The first three doses were administered using the facility's emergency drug kit, but the supply ran out....
The facility's internal incident tracking told the story clearly....
What makes this citation particularly notable is that it represents a **recurring problem**....
The facility's Weekend Supervisor used a remote control to unlock the front door for a departing visitor....
The facility received a citation for **actual harm** under federal nursing home regulations....
The only vital sign readings recorded during that period came on the day the resident was ultimately sent to the hospital....
The resident was subsequently hospitalized with septic shock....
## Repeated Controlled Medication Deficiencies The inspection revealed a troubling pattern at Maple Winds Healthcare and Rehabilitation, LLC....
The inspection revealed that the narcotic log book contained **no documentation that shift-to-shift counts had been completed at any time**....
Residents placed in secured units typically require that level of protection because they are at risk of wandering....
The April 2025 complaint investigation revealed a pattern of failed smoking safety protocols affecting multiple residents over a period of months....
Bernardo Drive in San Diego, during a June 2024 inspection....
The resident's Part A episode began on **January 5, 2025**, with the last covered day recorded as **February 3, 2025**....
Inspectors documented a detailed, minute-by-minute account of what occurred between 4:01 PM and 4:15 PM that day....
Both the cart surface and microwave were visibly unclean, covered with food debris and dried substances....
When surveyors reviewed the resident's Order Summary Report, **no physician order for oxygen administration existed anywhere in the record**....
The violation falls under **F-tag 0812**, which governs food procurement, storage, preparation, and service in skilled nursing facilities....
Admiral Doyle Drive** facility handled food without proper facial hair coverings....
## Medication Error Rate Exceeds Federal Limit Federal regulations require that nursing homes maintain a medication error rate below **5 percent**....