Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adviniacare Newton Wellesley during CMS and state inspections, most recent first.
Lack of Homelike Environment on Dementia Care Units: Surveyors observed both dementia care units had bare, undecorated hallways and resident rooms, with only a few family photos in less than half of rooms and multiple patched areas on the first-floor hallways and dining rooms that had not been painted. The Administrator said there were no formal plans to make the units more homelike and acknowledged the units looked sterile, while family members said the areas had nothing on the walls and were not really homelike.
Medical Director Did Not Attend Required QAPI Meetings. Review of QAPI sign-in records showed the medical director did not participate in one of the last four quarters, and the Administrator stated the new medical director was not reviewed on the QAPI program after hire. The Administrator said the new medical director did not attend QAPI until the October meeting, and for six months no physician attended to represent the medical director.
A facility failed to maintain an infection prevention and control program when staff did not consistently use EBP for residents with wounds and catheter-related care. A resident with pressure ulcers had an EBP order and door signage, yet staff were observed providing incontinence care and wound-related care with gloves only. Another resident with a pressure ulcer had no EBP order or signage, and a CNA provided care with gloves only while stating no special precautions were needed. A third resident receiving straight catheterization was not placed on EBP, and nursing staff reported using only universal precautions and gloves without a gown.
Failure to Notify MD/Dietician of Significant Weight Changes: Two residents with severe cognitive impairment had significant weight changes documented on weekly weights, but nursing records did not show notification of the MD, NP, or dietician. One resident had significant wt loss with no documented awareness by the MD or dietician, while the other had significant wt gain with no documented notification or review in the care plan, progress notes, or provider notes.
Failure to implement ordered abductor wedge for a resident at risk for skin breakdown. A resident with dementia, hemiplegia/hemiparesis, and severe cognitive impairment was ordered to have a Blue Soft abductor wedge in place when out of bed, and the care plan also directed use of the wedge between the knees in the wheelchair with placement checks each shift. Staff observed the resident in the wheelchair multiple times without the wedge, with the knees touching, and there was no documentation that the resident refused the intervention.
Failure to develop and implement a plan of care for a resident with multiple LUE contractures was identified. The resident had severe cognitive impairment and was observed with the left hand in a tight fist and the arm held against the chest. OT noted nursing was managing the contracture, but there were no MD orders, no active care plan for contracture management, and no nursing documentation of ROM or other contracture care. CNA and RN staff reported there was no specific contracture program in place, while the OT and DON acknowledged that nursing should have been providing and documenting ROM.
Failure to Monitor Significant Weight Loss: A resident with dementia, psychosis, and DM had ongoing significant weight loss while dependent for most ADLs. The record showed repeated weight declines, but nursing did not notify the MD or RD, the NP documented the loss as mild and of no concern, and the MD orders and progress notes did not address the weight loss or add new interventions.
Meal Service Delays and Improper Food Temperatures: Food service on a dementia unit was delayed, with residents waiting in the dining room before receiving trays or drinks. When a tray was checked, pureed eggs, bread, and oatmeal were only 100-102 degrees and thickened milk was 45 degrees, below the facility’s stated serving temperatures. The FSD said the tray was not warm enough to serve, and a CNA reported that many residents need meal assistance and food often gets cold before it can be served.
The facility failed to follow its water management plan for Legionella prevention and did not implement enhanced barrier precautions for a resident with a wound. Additionally, a nurse did not adhere to proper hand hygiene and dressing change protocols, placing supplies on an unclean surface and using the same gloves for multiple tasks. The Assistant Director of Nursing confirmed these lapses in infection control practices.
The facility failed to maintain resident dignity and privacy for two residents and six non-sampled residents. A CNA used a personal cell phone during care, violating the facility's policy and compromising residents' private space. Additionally, a resident was left exposed during care when the privacy curtain was not closed, contrary to the facility's policy. Interviews confirmed that cell phone use during care was not allowed, and privacy should have been maintained.
A resident with dementia and hypertension received Lisinopril despite physician-ordered parameters to hold the medication if systolic blood pressure was below 120. The facility's policy required checking vital signs before administering medications, but the resident's Medication Administration Record showed multiple instances of non-compliance. Interviews with nursing staff confirmed the medication should have been held, indicating a failure to follow the care plan and professional standards.
A facility failed to assess the use of pillows under a fitted sheet as a potential restraint for a resident with Alzheimer's and a history of falls. The resident's medical record lacked a restraint assessment, physician's order, or care plan documentation for this intervention. Staff confirmed the pillows were used to prevent the resident from moving or getting out of bed due to fall risks. The DON acknowledged the need for a restraint assessment.
A resident with severe cognitive impairment and requiring maximum assistance with personal hygiene was not provided with necessary facial hair removal, despite expressing a desire for assistance. Observations confirmed significant chin hair growth, and staff interviews indicated that this care should have been provided.
A facility failed to create a trauma-informed care plan for a resident with PTSD, who was unable to participate in a mental status exam due to severe cognitive impairment. The Social Worker expected an individual care plan for the resident, highlighting a lapse in providing trauma-informed care.
A facility failed to document a resident's wound during weekly skin checks, despite a physician's order and the resident's severe cognitive impairment. The nurse did not document the open area, assuming it was already recorded, which was confirmed as a deficiency by the DON.
Lack of Homelike Environment on Dementia Care Units
Penalty
Summary
The facility failed to provide a homelike environment on two dementia care certified nursing units. On 12/30/25 and 12/31/25, surveyors observed the first-floor and second-floor units lacked wall decorations in the hallways and resident rooms, with no pictures located on the walls other than a few family photographs in less than half of the resident rooms. The walls in the resident rooms and hallways were painted but undecorated, and the first-floor hallways and dining rooms had multiple patched areas that had not been painted. During interview, the Administrator stated there were no purchase orders or formalized plans to make the units more homelike and acknowledged that the units and resident rooms were sterile looking. Family members also stated that the hallways and rooms had nothing on the walls and were not really homelike.
Medical Director Did Not Attend Required QAPI Meetings
Penalty
Summary
The facility failed to ensure that the medical director attended QAPI meetings at least quarterly. Review of the QAPI sign-in records showed that the medical director did not participate in one of the last four quarters, specifically the 7/31/25 meeting. During interview, the Administrator stated that the facility’s QAPI meets monthly but the medical director attends only quarterly per regulation. The Administrator also stated that the previous medical director was fired in July 2025, that the new medical director hired on 8/5/25 was not reviewed on the QAPI program, and that the new medical director did not participate in QAPI until the October 2025 meeting. The Administrator said that for six months the medical director did not attend a QAPI meeting and no other physician attended to represent the medical director.
Failure to Implement EBP for Residents with Wounds and Catheter Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents with wounds or catheter-related care needs. Resident #5 had dementia, severe cognitive impairment, and multiple pressure ulcers, including an unhealed stage 3 pressure ulcer and a heel wound. Although the resident had an order for Enhanced Barrier Precautions (EBP), a surveyor observed a CNA providing morning incontinence care with gloves only, and later observed staff applying socks and a nurse removing the wrap from the resident’s left heel wound with gloves only. Signage on the resident’s door indicated EBP and directed staff to use a gown and gloves during care. Resident #9 had dementia, severe cognitive impairment, and an unhealed stage 2 pressure ulcer on the right buttock. The physician orders reviewed did not include an order for EBP, and the resident’s door did not have signage indicating EBP. During observation, a CNA provided morning incontinence care with gloves only and stated the resident was not on any special precautions needing PPE, despite the resident having a wound. Nursing staff later stated the resident should have been on EBP and that staff should have worn PPE, including a gown, during care. Resident #82 had urinary retention, severe cognitive impairment, and received straight catheterization every shift. The care plan addressed intermittent catheterization, but the physician orders did not include EBP. Surveyors observed no signage outside the room indicating EBP, and nursing staff stated they used only universal precautions with hand hygiene and gloves for straight catheterization and did not use a gown. The DON, who also served as Infection Preventionist, stated EBP are used for residents with wounds, IV lines, or urinary catheters, but said Resident #82 was not on EBP during urinary catheter procedures because she did not think it was needed.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician and dietician of significant weight changes for two residents. Resident #6, who was admitted with diagnoses including dementia, psychosis, and diabetes and was severely cognitively impaired and dependent for most ADLs, had a documented weight loss from 144.2 lbs. on 11/20/25 to 135.8 lbs. on 12/23/25, with the record identifying significant weight loss on 12/16/25 and 12/23/25. The care plan identified the resident as at risk for malnutrition and included interventions to monitor weight closely, but the record showed no progress notes indicating that nursing notified the physician or dietician of the significant weight loss. The only dietician note in the record was dated 11/25/25, and the physician progress note dated 12/29/25 did not indicate awareness of the weight loss or address it. Resident #1, who was admitted with diagnoses including dementia and depression and was severely cognitively impaired and dependent on staff for all ADLs, had a documented weight increase from 144.9 lbs. on 11/11/25 to 157.6 lbs. on 12/10/25 and 158.2 lbs. on 12/30/25, with the record identifying significant weight gain on 12/10/25 and 12/30/25. The care plan did not include notification of the physician for significant weight gain, and the progress notes for November and December 2025 did not show that the physician or NP was notified of the increase. The last dietician note was dated 12/2/25 and referenced the earlier weight, with no further dietician notes in the record; the physician note dated 12/20/25 and the NP note dated 12/5/25 did not indicate review of the resident’s weight.
Failure to Implement Ordered Abductor Wedge
Penalty
Summary
Resident #54, who was admitted in November 2023 with diagnoses including dementia, hemiplegia and hemiparesis, wrist drop, and weakness, was assessed by nursing staff on the most recent MDS as having severe cognitive impairment and being at risk for pressure ulcers. The physician’s order dated 10/6/25 directed use of a Blue Soft abductor wedge to the left lower extremity every day and evening shift, with removal and re-application as needed and placement checks. The resident’s skin breakdown care plan, revised the same date, directed use of the Blue Soft abductor wedge to both knees while in the wheelchair, removal in the evening, and checking placement and skin integrity every shift. On 12/30/25, the resident was observed in the wheelchair three times without the abductor wedge in place, and the knees were touching each other. On 12/31/25, the resident was again observed in the wheelchair without the abductor wedge, and the wedge could not be visualized in the room; the knees were again touching. Nursing progress notes did not indicate that the resident refused the wedge. During interview, Nurse #2 stated the resident should always have the wedge between the knees when out of bed because the knees touch, and said CNAs normally apply it when getting the resident up but did not. The DON stated the resident should have the wedge in place when out of bed as an intervention to prevent skin breakdown due to the knees touching from contractures.
Failure to Develop and Implement Contracture Management Plan
Penalty
Summary
Failure to provide care to maintain and/or improve range of motion (ROM) and manage a contracture occurred for Resident #72, who was admitted with diagnoses including contracture of the left shoulder, left elbow, left wrist, and left hand. The most recent MDS dated 11/6/25 indicated severe cognitive impairment with a BIMS score of 4 and functional limitations in ROM to one upper extremity. During observations on 12/30/25 and 12/31/25, the resident was seen sitting in a wheelchair or lying in bed with the left hand held in a tight fist and the left arm held tightly against the chest. Review of the OT note dated 8/20/25 stated that OT would not treat the contracture because nursing was managing it, but the record contained no physician orders for contracture management and no active plan of care addressing the contracture. Nursing progress notes did not document ROM or other contracture management being provided. CNA #2 stated there was no specific plan of care or program for ROM to the resident’s arm or hand, and Nurse #2 said there were no physician orders for ranging or contracture management and no plan of care being followed. The Regional OT stated nursing would continue ROM exercises to maintain function of the left arm and hand, and the DON stated there should be a plan of care in place and documented to prevent worsening of the contracture.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of Resident #6 by not ensuring significant weight loss was assessed and continually monitored. Resident #6 was admitted in November 2025 with diagnoses including dementia, psychosis, and diabetes, and was severely cognitively impaired with a Brief Interview for Mental Status score of 0 out of 15. The resident was dependent for most activities of daily living. The medical record showed weights declining from 144.2 lbs on 11/20/25 to 142.4 lbs on 11/25/25, 137.8 lbs on 12/9/25, 136.5 lbs on 12/16/25, 135.8 lbs on 12/23/25, and 135.9 lbs on 12/30/25, with the record identifying significant weight loss of 5.34% and 5.83%. Review of the record found only one dietitian progress note dated 11/25/25, and no additional dietitian notes documenting awareness of the ongoing weight loss. Progress notes from 11/20/25 through 12/28/25 did not show that the physician or dietitian was notified of the significant weight loss. The Nurse Practitioner documented mild weight loss of no concern on 12/9/25, and the physician progress note on 12/29/25 did not indicate awareness of the weight loss or address it. Physician orders for November and December 2025 did not show the weight loss was addressed or that new medical interventions were initiated. The care plan identified the resident as at risk for malnutrition and included monitoring weights closely, but the Dietician stated during interview that she was not aware of the weight loss and would have added an intervention if she had known.
Meal Service Delays and Improper Food Temperatures
Penalty
Summary
The facility failed to serve food that was palatable and at a safe and appetizing temperature on one of two certified dementia units. Facility policy stated that hot foods are to be served at 135 degrees or higher and cold foods or beverages at 41 degrees or lower. During a continuous observation in the first-floor dining room, 20 residents were present when the meal pass began, but no residents had been served food or drinks by 8:14 A.M. The first resident was not served until 8:17 A.M., and by 8:25 A.M. only six residents had received meals while 14 residents were still waiting at their tables for food and fluids. On the following morning, the surveyor observed 23 residents in the dining room, and five residents still had not received breakfast trays by 8:24 A.M. The surveyor checked one remaining tray in the food cart and found pureed eggs at 102 degrees, pureed bread at 100 degrees, oatmeal at 102 degrees, and thickened milk at 45 degrees. The FSD stated that food should be served at 130-140 degrees and said the tray was not warm enough to serve. A CNA stated that many residents on the first-floor unit require meal assistance, that it takes a long time to assist them all, and that food often gets cold before it can be served. The DON stated that meals should be served timely and at appropriate and safe temperatures.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its water management plan for Legionella prevention. The Maintenance Director, who has been with the facility since December 2023, stated that the facility does not test the water for Legionella, believing it to be the town's responsibility. However, the town's report only monitors minerals and other contaminants, not Legionella, indicating a lapse in the facility's compliance with its own water management program, which requires annual Legionella culture tests. The facility also failed to implement enhanced barrier precautions (EBP) for a resident with a wound. The facility's policy requires EBP for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. Despite this, there was no signage or evidence of EBP for the resident, and Nurse #1, who routinely completed the resident's wound treatment, did not use EBP, believing it was unnecessary. The Assistant Director of Nursing confirmed that EBP should have been utilized during wound care. Additionally, Nurse #1 did not follow the facility's policy for non-sterile dressing changes. The nurse placed dressing supplies on an unclean nightstand, failed to perform hand hygiene before applying gloves, and used the same gloves to handle both clean and dirty items, including picking up oxygen tubing from the floor and applying it to the resident. The nurse also did not change gloves or perform hand hygiene after removing the old dressing and before applying the new one. The Assistant Director of Nursing acknowledged that the nurse should have changed gloves and performed hand hygiene during the dressing change process.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide a dignified experience for several residents, including Resident #57 and Resident #11, as well as six non-sampled residents. For Resident #57 and six non-sampled residents, the deficiency occurred when a Certified Nursing Assistant (CNA) used a personal cell phone on speaker while providing care, which compromised the residents' private space and dignity. This action was against the facility's policy, which prohibits the use of personal cell phones during care, except in emergencies. The CNA was observed talking on the phone in a foreign language while in Resident #57's room and continued to do so while moving to an adjacent room, despite the presence of other residents. Interviews with the CNA, a nurse, the Ombudsman, and the Director of Nursing confirmed that cell phone use during care was not permitted. For Resident #11, the deficiency involved a failure to maintain privacy during care. The surveyor observed that the privacy curtain was not closed while Resident #11 was receiving care, leaving the resident exposed to their roommate. This was contrary to the facility's policy, which mandates the protection of resident privacy during personal care. The incident was further compounded when a nurse entered the room to perform a dressing change on Resident #11 without closing the privacy curtain, continuing to expose the resident. The Director of Nursing acknowledged that the curtain should have been closed during care to maintain the resident's dignity.
Failure to Adhere to Medication Parameters for a Resident
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with the comprehensive care plan and professional standards of quality for a resident with dementia and hypertension. The resident had a physician's order for Lisinopril, a medication to manage hypertension, with specific parameters to hold the medication if the systolic blood pressure was less than 120 or the heart rate was less than 60. Despite these parameters, the medication was administered on multiple occasions when the resident's systolic blood pressure was below the specified threshold. The facility's policy on medication administration required verification of vital signs related to parameters before administering medications. However, the Medication Administration Record (MAR) showed that the resident received Lisinopril on numerous dates when the blood pressure readings were below the physician-ordered parameters. Interviews with nursing staff confirmed that the medication should have been held under these circumstances, indicating a failure to adhere to the care plan and professional standards.
Failure to Assess Pillows as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of pillows placed underneath a fitted sheet as a potential restraint for a resident with Alzheimer's dementia and a history of repeated falls. The facility's policy on restraint use requires a comprehensive assessment to determine the safety and protective needs of a resident before applying any restraint. However, the medical record for the resident did not indicate that a restraint assessment had been completed for the use of pillows, nor was there a physician's order or care plan documentation for this intervention. Observations by the surveyor revealed that the resident was in bed with pillows placed underneath the fitted sheet at the hip/thigh level, and the foot of the bed was elevated. The resident was seen rolling in bed and attempting to kick their legs over the side, where the pillows were placed. Interviews with staff, including a CNA and a nurse, confirmed that the pillows were used to prevent the resident from moving or attempting to get out of bed due to the risk of falls. The Director of Nursing acknowledged that a restraint assessment should have been conducted to evaluate the use of pillows as a potential restraint.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, the facility did not assist Resident #57, who had severe cognitive impairment and required maximum assistance with personal hygiene, in removing unwanted chin hair. Despite the resident's inability to perform this task independently and their expressed desire for assistance, the facility did not ensure that facial hair removal was completed during care. Observations by the surveyor over several days confirmed that Resident #57 had significant chin hair growth, which was not addressed by the care staff. Interviews with the Certified Nurse Assistant (CNA) and the Director of Nursing (DON) revealed that facial hair removal should have been part of the resident's care routine, and there was no indication that the resident refused care. The failure to provide this aspect of personal hygiene care was contrary to the facility's policy and the resident's care plan, which specified maximum assistance for personal hygiene.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident was admitted in February 2023 and was unable to participate in the Brief Interview for Mental Status exam due to severe cognitive impairment. A review of the resident's care plans revealed that there was no trauma-informed plan developed for this individual. During an interview, the Social Worker, who was covering the building at the time, stated that she would have expected an individual care plan to be developed for a resident with a PTSD diagnosis. This indicates a lapse in the facility's responsibility to provide trauma-informed care for residents with specific mental health needs.
Failure to Document Resident's Wound in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate documentation in the medical record for a resident with a wound. The resident, who was admitted with diagnoses including dementia, hypertension, depression, and anxiety, had a severe cognitive impairment and was noted to have an open area on the mid-spine. Despite a physician's order for weekly skin checks and documentation, the facility did not document the resident's wound on a weekly skin check as required. The deficiency was identified when a surveyor observed a nurse performing a dressing change on the resident's spine. The nurse admitted to completing the skin check but did not document the open area, believing it was already documented. The Director of Nursing confirmed that skin checks should be accurately documented in the medical record, highlighting the facility's failure to adhere to its policy on risk and skin assessments.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wellesley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elizabeth Seton | 1.8 mi | ★★★★★ | 0 | 0 |
| Riverbend Of South Natick | 2.4 mi | ★★★★★ | 3 | 0 |
| Mary Ann Morse Nursing & Rehabilitation | 2.5 mi | ★★★★★ | 1 | 0 |
| Skilled Nursing Facility At North Hill (the) | 2.6 mi | ★★★★★ | 0 | 0 |
| Care One At Newton | 3 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.