Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Alliance Health At Baldwinville during CMS and state inspections, most recent first.
Improper Food Storage and Kitchen Sanitation: Surveyors found out-of-date, unlabeled, and improperly stored food items in the kitchen, including toast, sausage, and an unlabeled beverage and pudding-like substance. They also observed dust, debris, dirty floors, uncovered cereal, and crumb-covered sheet pans in the dry storage room, reach-in refrigerator, walk-in refrigerator, and steam table area. The FSD stated dietary cleaning assignments had not yet been developed and acknowledged the dirty conditions and uncovered items.
A resident with moderate cognitive impairment and a BIMS score below the facility’s threshold had two topical creams left within reach at the bedside without a self-administration assessment, physician order, or care plan for self-administration. The resident said the creams were used whenever itching occurred and did not know how often to use them, while the UM and DON stated the medications should not have been left at the bedside without the required assessment and order.
Failure to provide grooming assistance for facial hair removal. A resident with severe cognitive impairment, weakness, and need for substantial to maximum assistance with personal hygiene was observed multiple times with facial hair on the upper lip, chin, and cheeks. CNA and DON interviews confirmed the resident did not refuse care, was dependent for shaving, and that facial hair removal was expected as part of routine morning grooming, but it was not completed.
Improper Foley Drainage Bag Positioning: A resident with an indwelling urinary catheter and diagnoses including obstructive and reflux uropathy had the Foley drainage bag observed touching the floor while seated in a wheelchair and again while in bed, without a protective barrier. The CNA stated the bag should not touch the floor and the IP said it should be kept off the floor because germs on the floor could get into the bag and cause infection.
Failure to Provide Paper Copy of NOMNC: A resident receiving Medicare Part A skilled services had an activated HCP, and facility staff gave the NOMNC information by phone but did not document mailing the required paper copy to the HCP. Record review and staff interviews confirmed there was no evidence that the NOMNC was provided in person or mailed after the telephone notice.
A resident with an initial negative PASRR screen later developed escalating aggressive behaviors, required involuntary ED transfer and inpatient psych hospitalization, and was newly diagnosed with bipolar disorder with psychotic features. The resident also received and continued olanzapine, but the facility did not refer the resident for PASRR Resident Review when the significant change occurred.
A CNA in a LTC facility failed to change PPE between serving a COVID-19 positive resident and a COVID-19 negative resident, contrary to infection control standards. The CNA acknowledged the error, and the DON confirmed it was against facility expectations, risking cross-contamination.
The facility failed to update its Pneumococcal Vaccination policy according to CDC guidance, resulting in three residents not being properly offered or administered the PCV20 vaccine. One resident was not given the opportunity to consent or decline the vaccine upon admission, while two others had consented but did not receive the vaccine.
A resident with a sacral ulcer did not receive proper care as the facility failed to set the specialty air mattress to the correct weight and did not provide heel booties as ordered. Additionally, the facility did not follow through on lab work recommendations from the wound physician. Staff interviews revealed a lack of awareness and documentation regarding the resident's care plan.
A facility failed to implement Contact Precautions for a resident with VRE, as a Social Worker entered the resident's room twice without donning the required PPE, despite clear signage and available PPE. The SW was aware of the precautions but misunderstood the necessity of PPE without direct contact. The Infection Preventionist acknowledged the need for further staff education on precautionary measures.
Improper Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to follow professional standards of practice for food storage and environmental cleaning in the main kitchen. During the initial kitchen walk-through, the surveyor observed in the dry food storage room a one-gallon clear plastic bag containing 20 pieces of toasted bread labeled and dated 12/19/25, along with dried yellow, brown, and white substances on the floor under the food storage racks. In the reach-in refrigerator, there was a clear plastic cup with a straw through the lid containing a coffee-colored liquid and ice that was unlabeled and undated. In the walk-in refrigerator, the surveyor observed a sealed zip-lock bag labeled as Italian sausage and dated 12/17/25, a covered clear plastic container half filled with a gelatinous yellow substance that was unlabeled and undated, dust on the refrigerator fan casing and ceiling above the fan, and hard chunks of yellow and brown debris under the food storage racks with torn pieces of clear packing tape and cardboard box fragments. On the shelving unit below the steam table service area, there was an opened and uncovered box of cream of wheat cereal and three silver metal sheet pans coated with dry white and brown crumb-like material. The Food Service Director stated that cleaning assignments for the dietary department had not yet been developed and acknowledged that the dirty areas and uncovered food items should have been cleaned or covered.
Unassessed bedside access to topical medications
Penalty
Summary
The facility failed to ensure that it was appropriate and safe for medications to be self-administered for one resident with cognitive communication deficit and moderate cognitive impairment. The resident’s MDS dated 12/18/25 showed a BIMS score of 11 and required supervision or touching assistance for several activities of daily living. The facility policy required a BIMS score of 13 or greater, completion of a self-administration medication assessment, physician notification and order if self-administration was approved, and a care plan addressing self-administration and ongoing monitoring. The record contained no evidence of a self-administration assessment, no physician order for self-administration, and no care plan related to self-administration. Surveyors observed the resident in bed with two tubes of Diphenhydramine Zinc Acetate cream and one tube of Nystatin cream within reach on the over-the-bed table on multiple occasions, with no staff in the immediate area. The resident stated the creams were used whenever he or she felt itchy and said he or she was unaware of how often they should be used. The record showed an order for Nystatin cream twice daily to the groin and scrotum, but no physician order for Diphenhydramine Zinc Acetate cream. The UM and DON both stated the resident should not have the medications at the bedside because the resident had not been assessed to know how and when to safely use them.
Failure to Provide Grooming Assistance for Facial Hair Removal
Penalty
Summary
Facility staff failed to provide facial hair removal as part of ADL grooming for Resident #84, who was admitted with senile degeneration of the brain, cognitive communication deficit, an unspecified mental disorder due to an unknown psychological condition, and muscle weakness. The resident’s care plans and CNA Kardex indicated the resident was confused, required cues and supervision for grooming, and needed substantial to maximum assistance with personal hygiene. The MDS also showed severe cognitive impairment with a BIMS score of 1 out of 15 and no rejection of ADL care. Survey observations on multiple occasions showed the resident dressed and seated or lying in bed with facial hair present on the upper lip and chin, later extending to the cheeks. During interview, CNA #1 stated the resident did not refuse care, could wash the face when given a washcloth, but was dependent for removal of facial hair. CNA #1 said facial hair should have been removed during morning care and that if it was not done then another shift should complete it later the same day or the next day. The DON stated the facial hair should have been removed by the night shift during morning care and expressed concern that the resident could be embarrassed. The SDC stated shaving and facial hair removal were part of grooming for all residents and that if a CNA could not remove the facial hair during morning care, the CNA should try again later that day or the next day.
Improper Foley Drainage Bag Positioning
Penalty
Summary
The facility failed to provide appropriate catheter care for Resident #58, who was admitted with diagnoses including obstructive and reflux uropathy and had an indwelling urinary catheter. The Minimum Data Set indicated the resident did not demonstrate rejection of care and required substantial to maximum assistance for showering, toileting, and dressing below the waist. The facility’s policy stated that the drainage bag should always be kept below the level of the resident’s bladder and off the floor. Survey observations showed the resident’s Foley catheter drainage bag connected under the wheelchair seat and touching the dining area floor without a protective barrier. The same condition was later observed while the resident was lying in bed, with the drainage bag touching the floor. During interview, the CNA assigned to the resident stated the bag should not touch the floor and should be in a protective privacy bag, and said floor contact can cause infections. The Infection Preventionist also stated the drainage bag should be kept off the floor because germs on the floor could get into the drainage bag and cause infection.
Failure to Provide Paper Copy of NOMNC
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) was accurately issued for one resident receiving Medicare Part A skilled services. Resident #95 was admitted in June 2025, was not responsible for him/herself, and had an activated Healthcare Proxy on 6/21/25. The resident began Medicare Part A skilled services on 6/17/25, and the last covered day was 7/3/25. Facility staff contacted the HCP by telephone on 7/1/25 at 11:30 A.M. to provide the NOMNC information. The record did not show that a paper copy of the NOMNC form was mailed to the HCP after the telephone notice, and review of the NOMNC form and clinical record failed to indicate that the required paper copy was provided. During interviews, the Regional Clinical Reimbursement staff member stated the facility refers to CMS guidelines for proper delivery of NOMNC forms, and the Social Worker stated there was no documentation that the NOMNC was provided in person or that a paper copy was mailed to the HCP after the telephone notice.
Failure to Refer Resident for PASRR Review After Psychiatric Change
Penalty
Summary
The facility failed to coordinate a PASRR assessment when Resident #3 experienced a significant change in mental status and met criteria for a Resident Review. The resident was admitted in February 2021 with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, and the initial PASRR Level I screening was negative for serious mental illness because there was no documented mental illness or related disorder and no qualifying psychiatric treatment history at that time. In October 2023, the resident exhibited escalating behavioral symptoms, including verbal abuse toward staff, threats to shoot staff if a gun were available, yelling, throwing items, refusing medications and care at times, and refusing antidepressant medication recommended by the physician. The physician documented physically and verbally aggressive behavior, noncompliance with the behavior modification plan, and involuntary transfer to the ED for psychiatric evaluation due to risk of harm to staff and other residents. The resident was then admitted for acute psychiatric hospitalization and was newly diagnosed with bipolar disorder, current episode manic severe with psychotic features. During the hospitalization, the resident received olanzapine, and the hospital physician recommended continuing the medication after discharge. The resident returned to the facility on [DATE], and the record showed no evidence of referral to the PASRR program at that time. The resident later remained on olanzapine, and the social worker stated the facility became aware in May 2025 that the resident had not been referred for PASRR Resident Review after the psychiatric hospitalization, bipolar diagnosis, and antipsychotic use. The social worker said the referral was not submitted until 9/4/25 and was rejected for additional information, which had not yet been submitted at the time of the interview.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to infection control standards on Unit One, affecting two residents. The deficiency was identified during a meal tray pass when a CNA did not change personal protective equipment (PPE) between serving a COVID-19 positive resident and a COVID-19 negative resident. This action was contrary to the facility's policy and CDC guidelines, which require changing gowns and gloves between residents to prevent cross-contamination. Resident #3, who tested positive for COVID-19, required assistance with meal setup. The CNA, wearing an N95 mask, gown, gloves, and goggles, set up Resident #3's meal tray and then proceeded to set up the meal tray for Resident #6 without changing the gown and gloves. Resident #6 had not tested positive for COVID-19 and was at risk for respiratory distress due to congestive heart failure. The CNA acknowledged the mistake during an interview, stating that she should have served the COVID-19 negative resident first and changed PPE before serving the COVID-19 positive resident. The Director of Nursing confirmed that the CNA's actions were not in line with the facility's expectations, which aim to prevent potential cross-contamination between residents.
Failure to Implement Updated Pneumococcal Vaccination Guidance
Penalty
Summary
The facility failed to implement updated timing guidance for Pneumococcal Vaccinations and ensure that these vaccinations were offered and administered as consented to for three residents. The facility's policy on Pneumococcal Vaccination had not been updated to reflect the current CDC guidance, which led to a lack of proper vaccination offerings and administration. The Infection Preventionist (IP) was unaware of the need for an updated policy and was waiting for a new policy to be developed, which was not provided to the survey team by the time of the survey exit. For one resident, there was no documented evidence that the opportunity to consent to or decline the Pneumococcal Vaccine was provided upon admission, despite the resident being eligible for the PCV20 vaccine. The IP confirmed that there was no vaccine consent or declination form completed for this resident at the time of admission, which was a requirement. Two other residents had consented to receive the PCV20 vaccine, but there was no documented evidence that the vaccine was administered to them after consent was obtained. The IP acknowledged that consents had been obtained for these residents, but the vaccines had not been administered as they should have been.
Failure to Implement Pressure Ulcer Care Interventions
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with a pressure ulcer. The resident, who was admitted with a sacral ulcer and had diagnoses including Myasthenia Gravis and Diabetes, was supposed to have a specialty air mattress set at 200 pounds and wear heel booties as per physician orders. However, observations revealed that the mattress was set at 150 pounds, and the resident was not wearing the booties, which were not even present in the room. The facility's policy required regular inspection and intervention for skin issues, but these measures were not properly implemented. Additionally, the facility did not follow through on the wound physician's recommendations for lab work, specifically the Glycosylated Hemoglobin (HgbA1c) level, which was not addressed or drawn since the recommendation was made. The resident's clinical record lacked documentation of the lab work being completed, and there was no evidence that the resident refused the interventions, except for one instance where the resident declined the booties. Interviews with facility staff, including a CNA and a nurse, revealed a lack of awareness and proper documentation regarding the resident's care plan. The Assistant Director of Nurses and the Corporate Nurse acknowledged issues with communication and documentation of the wound physician's recommendations. The facility staff could not provide evidence that the necessary lab work was addressed by the physician before the survey exit.
Failure to Implement Contact Precautions for Resident with VRE
Penalty
Summary
The facility failed to implement Transmission Based Precautions (TBP) for a resident diagnosed with an infection, specifically Vancomycin-Resistant Enterococcus (VRE) in the urine, which required Contact Precautions. The facility's policy and CDC guidelines mandate that healthcare personnel wear gowns and gloves for interactions involving contact with the patient or potentially contaminated areas. Despite these requirements, a Social Worker (SW) entered the resident's room twice without donning the necessary personal protective equipment (PPE), even though a Contact Precaution sign was posted outside the room and a bin containing PPE was available. The SW acknowledged awareness of the Contact Precautions but believed PPE was unnecessary as there was no direct contact with the resident. This misunderstanding led to a breach in protocol, as the SW did not adhere to the signage instructions requiring PPE for room entry. The Infection Preventionist (IP) later confirmed that all staff should perform hand hygiene and wear gowns and gloves before entering a Contact Precaution room, indicating a need for further staff education on precautionary measures.
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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 Baldwinville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wachusett Manor | 5.1 mi | ★★★★★ | 8 | 0 |
| Gardner Rehabilitation And Nursing Center | 5.1 mi | ★★★★★ | 13 | 0 |
| Quabbin Valley Healthcare | 10.8 mi | ★★★★★ | 24 | 0 |
| Highlands, The | 12.9 mi | ★★★★★ | 9 | 0 |
| Fitchburg Healthcare | 13.7 mi | ★★★★★ | 17 | 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.