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Health Inspection

Regalcare At Courtyard-medford

March 11, 2025 · Medford, MA · 200 Governors Avenue
Citations 3
CMS Rating 1/5
Beds 224
Provider ID 225545
Healthcare Facility
Regalcare At Courtyard-medford
Medford, MA  ·  View full profile →
Inspection Summary

REGALCARE AT COURTYARD-MEDFORD in MEDFORD, MA — inspection on March 11, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF725
Minimal harm or 41456 Few free from restraints, out of a total sample of 40 residents. affected

Review of Resident #130's most recent Minimum Data Set (MDS) assessment, dated 12/19/24, indicated the Resident was unable to complete the Brief Interview for Mental Status exam and staff had assessed him/her to have severe cognitive impairment.

The MDS also indicated Resident #130 was dependent on staff for all care.

On 3/4/25 at 9:04 A.M., Resident #130 was observed lying in bed, leaning to the left side of the bed and his/her head was against the side rail. A pillow was observed under his/her right arm.

The bed was slanted to the left and approximately 5 inches from the radiator/wall and not in the center of his/her side of the room.

225545

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225545 B.

Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regalcare at Courtyard-Medford 200 Governors Avenue Medford, MA 02155

Review of Resident #110's most recent Norton Pressure Ulcer assessment, dated 1/8/25, indicated the Resident has double incontinence and is a high risk for pressure ulcer development.

Review of Resident #110's ADL care plan indicated the following intervention:

- Provide resident/patient with limited assist of 1 for toileting after meals and as needed.

Review of Resident #110's incontinence care plan failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed.

During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed.

During an interview on 3/7/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #5 said she did not provide care to Resident #110 while the surveyor was off the unit. CNA #5 said Resident #110 requires maximal assistance from staff for toileting and is incontinent of both bladder and bowel. CNA #5 said she provided care to Resident #110 and assisted him/her back to lunch after bed. CNA #5 said she did not provide incontinent care to the Resident when she placed him/her back in bed and she was waiting until after she completed her afternoon paperwork

225545

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225545 B.

Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regalcare at Courtyard-Medford 200 Governors Avenue Medford, MA 02155

Review of the facility policy titled, Abuse Prohibition, dated 3/2022, indicated the following:

Purpose:

- Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property, Every resident in the facility will always be treated with respect and dignity,

- Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.

Policy:

- Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteer staff, family members, friends, or other individuals,

- Staff will refrain from all actions that could be considered abuse, mistreatment, neglect, exploitation, and/or misappropriation.

1.) For Resident #138, the facility failed to ensure staff provided necessary care to reposition and provide incontinence care resulting in the deterioration of a pressure wound.

Resident #138 was admitted to the facility in June 2024 with diagnoses including functional urinary incontinence and dementia.

Review of the most recent Minimum Data Set (MDS) assessment, dated 1/29/25, indicated Resident #138 had severe cognitive impairment based on a Staff Assessment for Mental Status.

The MDS further indicated Resident #138 had a stage three pressure ulcer, required substantial/maximal assistance to roll in bed, was always incontinent of bowel and bladder, and was dependent of staff for toileting hygiene and transfers.

Review of Resident #138's medical record indicated he/she had been transferred to the hospital on 3/4/25 for deteriorating coccyx wound with increased size, drainage, and foul smell.

225545

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225545 B.

Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regalcare at Courtyard-Medford 200 Governors Avenue Medford, MA 02155

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 MEDFORD, 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 REGALCARE AT COURTYARD-MEDFORD or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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