Mayflower Home

In the surveyor’s words

From the most serious findings on record at Mayflower Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF727Jul 11, 2024

  Based on daily staffing sheets, punch detail, policy review and staff interviews, the facility failed to have 8 hours Registered Nurse (RN) coverage. The facility reported a census of 28 residents. Findings include: The Daily Healthcare (HC) Schedule, dated 6/16/24, revealed Staff B, Registered Nurse, worked the night shift on 6/16/24. The review of the facility punch detail reflected on 6/16/24 Staff B clocked in at 10:07 PM and clocked out 6/17/24 at 6:37 AM. The facility couldn't provide additional information including Daily HC schedules or punch detail regarding RN coverage on 6/16/24. […]

• No harm, potential for more than minimal, isolatedF580Jul 9, 2026

  Based on clinical record review, policy review, and staff interview, the facility failed to notify the provider of abnormal blood sugars and of a weight loss for 1 of 5 residents reviewed for high risk medications(Resident #20). The facility reported a census of 31 residents. Findings included:The Minimum Data Set (MDS) assessment tool, dated 6/17/26, listed diagnoses for Resident #20 which included diabetes (a disease which caused abnormal blood sugars), heart failure, and high blood pressure and listed her Brief Interview for Mental Status (BIMS) score as 9 out of 15, indicating moderately impaired cognition. a. […]

• No harm, potential for more than minimal, isolatedF550Apr 9, 2026

  Based on clinical record review, written resident statement, resident interviews, staff interviews and policy review, the facility failed to ensure residents were treated with respect and dignity for 2 of 6 residents reviewed for dignity (Residents #1 and Resident #9). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 1/9/26, documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS reflected the resident had diagnoses to include progressive neurological conditions, Parkinson's disease and anxiety disorder. […]

• No harm, potential for more than minimal, isolatedF658May 29, 2025

  Based on observation, clinical record review, policy review, and staff interview, the facility failed to follow physician's orders for 1 of 3 residents reviewed for pressure ulcers (Resident #32). The facility reported a census of 31 residents. Findings include: The Minimum Data Set assessment tool, dated 5/16/25, listed diagnoses for Resident #32 which included heart failure, diabetes, and obesity. The MDS listed the Brief Interview for Mental Status(BIMS) score as 14 out of 15, which indicated intact cognition. The MDS documented the resident had 1 unhealed pressure ulcer. […]

• No harm, potential for more than minimal, isolatedF684May 29, 2025

  Based on clinical record review, facility policy review, and staff interviews, the facility failed to assess, intervene, and notify the physician as directed to ensure bowel regularity for 3 of 4 residents (Residents #2, #18, and #21) reviewed. The facility reported a census of 31 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment tool, dated 3/21/25, for Resident #2 revealed a list of diagnoses which included a seizure disorder, depression, and severe obesity. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, which indicated intact cognition. Review of the Bowel Elimination Report revealed a lack of documentation to indicate if Resident #2 had a bowel movement from 5/20/25 to 5/28/25. […]