Care Village at Mattapan

In the surveyor’s words

From the most serious findings on record at Care Village at Mattapan, in the surveyor’s own words.

• Actual harm, isolatedF760May 13, 2026

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required 1) anticonvulsant medication for epilepsy (seizure disorder) and 2) an anticoagulant (blood thinner) for a newly diagnosed deep vein thrombosis (DVT, blood clot), the Facility failed to ensure he/she was free from a significant medication error, when upon re-admission to the facility, his/her medication orders were not accurately reconciled by nursing resulting multiple missed doses of both medications. […]

• Actual harm, isolatedF600Feb 3, 2022

  Based on record review and interview, the facility failed to prevent abuse for 1 Resident (#59) from Resident (#18) out of a total sample of 29 residents. Findings include: Review of the facility policy, titled Abuse Prohibition, dated 12/2018, indicated the following: *Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. […]

• Actual harm, isolatedF688Mar 11, 2021

  Based on observation, record review, and interview, the facility failed to ensure appropriate equipment and assistance were provided for contractures to prevent worsening of range of motion for one Resident (#14) out of a total sample of 19 residents. Findings include: Resident #14 was admitted to the facility in August 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated 12/5/2020, indicated Resident #14 was totally dependent for bathing, dressing, hygiene, bed mobility, transfers, and eating. […]

• Actual harm, isolatedF656Jan 27, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for bed mobility, positioning and the use of side rails while in bed, the Facility failed to ensure staff implemented and followed his/her plan of care. On 01/07/21, Certified Nurse Aide (CNA) #1, without the assistance of another staff member, assisted Resident #1 with bed mobility and positioning, as he/she rolled over in bed, he/she grabbed on to the side rail, the side rail fell and Resident #1 rolled off the bed and fell on to the floor, as a result his/her gastrostomy tube ([DEVICE], a flexible feeding tube placed through the abdominal wall and into the stomach, used for feeding meals and medications) became dislodged, he/she sustained a left… […]

• Actual harm, isolatedF689Jan 27, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for bed mobility and positioning and the use of side rails while in bed, the Facility failed to ensure staff provided the necessary level of assistance to maintain Resident #1's safety. On 01/07/21, Certified Nurse Aide (CNA) #1, without the assistance of another staff member, assisted Resident #1 with bed mobility and positioning and as Resident #1 rolled over in bed and grabbed onto the side rail, the side rail fell and he/she rolled out of the bed and fell on to the floor, as a result his/her gastrostomy tube ([DEVICE], a flexible tube placed through the abdominal wall and into the stomach used for feeding meals and medications) became dislodged,… […]