Care Village At Mattapan
Inspection Findings
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when nursing failed to document
a urinary catheter change.Findings include:The Facility Policy, titled, Charting and Documentation, undated, indicated observations, medications administered, services performed, etc., would be documented in the residents' clinical records.Resident #1 was admitted to the Facility in May 2023, diagnoses included Cauda Equina Syndrome (injury or herniated disk compresses nerve roots at the bottom of your spinal cord. The cauda equina nerves communicate with your legs and bladder. It causes back pain, weakness and incontinence) and neuromuscular dysfunction of the bladder.Review of Resident #1's August and September 2025 active Physician's Orders, indicated he/she had a physician's order, dated as effective since 05/19/23, which indicated nursing staff may change his/her indwelling urinary catheter as needed for blockage.Further review of Resident #1's August and September 2025 active Physician's Orders indicated he/she had a second Physician's Order, dated as effective since 05/19/23, which indicated nursing staff may change his/her indwelling urinary catheter as needed for blockage or dislodgement every eight hours as needed.Review of Resident #1's Hospital History and Physical (H&P), dated 09/13/25, indicated he/she was transferred from the Facility to the Hospital Emergency Department with symptoms of a urinary tract infection. The Hospital H&P indicated his/her indwelling urinary catheter was last changed at the Facility two and a half to three months earlier.Review of the Facility's internal investigation, dated 09/25/25, indicated the Facility discovered through their investigation process that Nurse #1 had changed Resident #1's indwelling urinary catheter on 08/16/25, but had not documented the catheter change anywhere.Review of Resident #1's Treatment Administration Record (TAR) for August 2025 indicated nursing did not check off that his/her indwelling urinary catheter was changed on any days that month.Review of Resident #1's medical record indicated there was no documentation to support that nursing changed his/her indwelling urinary catheter on 08/16/25.During a telephone interview on 10/15/25 at 02:26 P.M., Nurse #1 said that on 08/16/25 she had changed Resident #1's Foley catheter at his/her request due to discomfort and blockage. Nurse #1 said she did not document the procedure anywhere in Resident #1's medical record but should have.During an interview on 10/15/25 at 09:45 A.M., the Director of Nurses (DON) said Nurse #1 should have documented Resident #1's indwelling urinary catheter change
on 08/16/25, and said nursing should document care related to indwelling urinary catheters daily but had not.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Care Village at Mattapan in MATTAPAN, 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 MATTAPAN, 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 Care Village at Mattapan or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.