M I Nursing & Restorative Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident #1's daughter and health care proxy, with Resident #1 present, said she received a call from the overnight nurse on 09/03/25 at approximately 3:00 A.M., to tell her that he believed Resident #1's arm was broken and that he/she was being sent to the emergency room. Resident #1's daughter said the nurse told her that a CNA provided care alone to the Resident and this confused her because she believed the Resident required two staff members for any type of care. Resident #1's daughter said that when asked, the nurse could not say why two people were not available to provide care. The surveyor did not attempt an
interview with the Resident at this time because his/her daughter said he/she did not talk much. During an
interview on 10/02/2025 at 9:21 A.M., CNA #1 said she has been Resident #1's primary CNA during the day shift for a very long time. CNA #1 said Resident #1 is dependent for all care and requires two staff to assist for all toileting and bed mobility tasks. CNA #1 said two CNAs are required to ensure safety for the Resident because the Resident is too heavy for one person to move on their own. During a telephone
interview on 10/02/2025 at 3:10 P.M., CNA #2 said she provided care to Resident #1 on September 3, 2025, when the incident occurred. CNA #2 said she had been providing care to Resident #1's roommate and when leaving the room observed Resident #1 to be soiled. CNA #2 said Resident #1 was not on her assignment, however, because the Resident was soiled, she decided to provide incontinence care. CNA #2 said she attempted to ask for help from the other CNA on duty, but he was busy, so she began to provide care on her own. CNA #2 said she did not ask the nurse on duty for assistance. CNA #2 said as she began to roll Resident #1 to his/her left side, she heard a crack in the Resident's right arm, and she then went to get the nurse for help. CNA #2 said all CNAs have the ability to look up Kardex or care plan information, however she did not look up information prior to her shift. CNA #2 said she was also aware that Resident #1 required two people for care, but she decided to provide care on her own anyway and did not ask the nurse or wait until the other CNA was available. During a telephone interview on 10/02/2025 at 3:12 P.M., Nurse #1 said the staff providing care to the residents are able to access and view any resident care plan or Kardex to see the level of care required. Nurse #2 said Resident #1 has always required two staff for personal care and bed mobility tasks because he/she is very heavy and for safety of both staff and the Resident, one person cannot do it alone. Nurse #1 said CNA #2 provided care to Resident #1 by herself and never asked him to assist her. Nurse #2 said he will assist all CNAs during his shift as needed or asked. During an interview on 10/02/25 at 2:02 P.M., the Director of Nursing said CNA #2 observed Resident #1 to be soiled in bed, could not find help from the other CNA and provided care to the Resident herself. The Director of Nursing said she never asked CNA #2 if she asked the nurse for help and was unsure of this. The Director of Nursing said that while CNA #2 was providing care, she heard Resident #1's arm snap and immediately got the nurse for help and the Resident was sent out to the hospital after he/she was assessed, and the Nurse Practitioner and health care proxy were notified. The Director of Nursing said CNA #2 was relatively new to the floor and was not familiar with the residents. The Director of Nursing said
the Kardex is available for the staff to review, and she was aware CNA #2 did not review this prior to starting her shift or providing care to Resident #1. The Director of Nursing said CNA #2 did not follow the plan of care written for Resident #1
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M I NURSING & RESTORATIVE CENTER in LAWRENCE, MA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LAWRENCE, MA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from M I NURSING & RESTORATIVE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.