Average — CMS composite of the measures below.
A standard survey is most likely before 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 Maples during CMS and state inspections, most recent first.
The facility failed to solicit and consider input from direct care staff, residents, resident representatives, and family members when completing the facility assessment. CMS guidance required active involvement from leadership and direct care staff and solicitation of resident and family input, but the assessment listed facility leaders and staff without showing that those required perspectives were included. The Administrator stated no resident or family input was solicited when the assessment was developed and that it had not been reviewed since it was last reviewed by the facility.
Unsecured wound care supplies and antifungal powder left at bedside. A resident with dementia and a stage 4 pressure ulcer had wound cleanser bottles left on a bureau and bedside table in the room, and another resident had antifungal powder left on a bedside table. An LPN stated the items should have been kept in the treatment cart, and the DON said treatments should be safely secured and not left at the bedside due to a safety risk for wandering residents.
Infection prevention and control failures included staff not using gowns during EBP high-contact care for a resident with a stage 4 pressure ulcer and dementia, despite posted EBP signage and available PPE. The facility also kept incomplete and inaccurate infection surveillance forms, with missing symptom, culture, and antibiotic details and some residents incorrectly documented as meeting McGeer criteria.
A resident with dementia and a stage 4 pressure ulcer had an air mattress ordered at 150 lbs., but staff observed the mattress set at 200 lbs. A second resident with COPD and respiratory failure had O2 ordered at 2 LPM via NC continuously, but surveyors repeatedly found the concentrator set at 2.5 LPM instead of the ordered rate; the Unit Manager and DON acknowledged the mismatch.
A resident consented to receive the current COVID-19 vaccine, but the dose was not given and the record showed no vaccine since the prior year. Nursing notes did not document administration or a reason for non-administration. The IP said the vaccine was missed because vaccinations on that floor had already been completed, and the DON stated the resident should have received it but did not due to an error.
Inaccurate wound documentation was found for a resident with dementia and a stage 4 pressure ulcer. The resident’s wound was documented by the consultant wound provider as being on the right buttock, but the ADON’s IDT wound notes repeatedly recorded it as a left hip or left ischium wound. The ADON acknowledged the charting error and stated she was not aware the location had been documented inaccurately.
A resident identified as a high fall risk and on anticoagulant medication experienced five falls in a month, resulting in a subarachnoid hemorrhage. Despite being on a fall prevention care plan, the facility failed to provide adequate supervision and implement effective interventions, leading to repeated falls. Staff interviews revealed inconsistencies in supervision and care plan adherence, with 1:1 supervision only implemented after a serious injury occurred.
A resident with severe cognitive impairment and on anticoagulant therapy experienced a fall resulting in a subarachnoid hemorrhage. The Nurse Practitioner ordered the discontinuation of the anticoagulant, but the facility failed to notify the resident's representative of this change, contrary to their policy requiring prompt communication of condition changes.
A facility failed to provide a complete discharge summary for a resident discharged to an Assisted Living Facility. The discharge paperwork lacked essential information such as admission and discharge dates, diagnosis, and physician signature. Staff interviews revealed that while a Continuity of Care Document was reviewed with the resident, the discharge plan of care was not completed, and the physician did not finalize the discharge summary.
The facility failed to ensure timely AIMS assessments and proper documentation for PRN psychotropic medication use for two residents. One resident did not receive a timely AIMS assessment for antipsychotic medication, while another had PRN Trazodone orders without re-evaluation or clinical rationale. Staff interviews confirmed these deficiencies.
Facility Assessment Lacked Required Input
Penalty
Summary
The facility failed to solicit and consider input from direct care staff, residents, resident representatives, and family members when conducting the facility assessment used to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies. CMS guidance reviewed by surveyors stated that active involvement in the assessment process must include nursing home leadership and management, direct care staff, and solicitation and consideration of input from residents, resident representatives, and family members. The facility’s policy on the Facility Assessment Tool stated that the assessment should include the administrator, medical director, director of nursing, and input from a representative of the governing body, and that facilities are encouraged to seek input from residents, their representatives, or families. The facility assessment, last updated 8/1/24 and reviewed 1/13/25, listed participants including the Administrator, DON, governing body representatives, medical director, human resources director, staff development coordinator, rehab director, staff nurse, and CNA, but it did not reflect input from direct care staff or from residents, resident representatives, or family members. During interview, the Administrator stated the facility assessment was reviewed in January 2025, no resident or family input was solicited when developing it, and it had not been reviewed since January 2025.
Unsecured wound care supplies and antifungal powder left at bedside
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in a safe and secure manner for two residents. Resident #9, who was admitted in November 2024 and had diagnoses including dementia and a stage 4 pressure ulcer to the right buttock, had a current order for wound care to the right ischium using Vashe wound cleanser, pat dry, then apply Alginate and a foam dressing twice daily and as needed. The resident’s MDS assessment dated 7/10/25 indicated severe cognitive impairment with a Brief Interview for Mental Status score of 3 out of 15 and a stage 4 pressure ulcer. During observations on 9/3/25 and 9/4/25, the surveyor found bottles of Vashe Wound Cleanser on the resident’s bureau and bedside table, and bottles of DermaKlenz Plus Antimicrobial Wound Cleanser on the bedside table in the room. On 9/4/25, the surveyor also observed a bottle of antifungal powder on the bedside table in Resident #121’s room. During interview, Nurse #2 stated the wound treatment supplies and antifungal powder were supposed to be kept in the treatment cart and should not have been left out in the residents’ rooms. The DON stated treatments should be safely secured and not left at the bedside due to a safety risk for wandering residents on the unit.
Infection Prevention Program and Surveillance Documentation Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. One failure involved Resident #9, who was admitted in November 2024 with dementia and a stage 4 pressure ulcer to the right buttock. The resident’s MDS dated 7/10/25 showed severe cognitive impairment with a Brief Interview for Mental Status score of 3 out of 15 and confirmed the stage 4 pressure ulcer. On 9/3/25, an Enhanced Barrier Precautions sign was observed posted at the resident’s room, and the physician’s orders included maintaining EBP every shift. During observation on 9/4/25, two CNAs were seen transferring Resident #9 from the bed to a Broda chair while an EBP sign was posted and gowns were available in the room on a cart. Both CNAs did not wear gowns during the high-contact care activity. After the observation, both CNAs stated they knew the resident was on EBP and should have worn gowns but did not. The ADON/IP later stated that gowns should have been worn during the transfer because it was a high-contact care activity. The facility also failed to keep its infection surveillance documents complete and accurate each month. The facility’s surveillance form was intended to track symptoms, cultures, antibiotics, McGeer criteria, and related infection information, but multiple entries for June, July, and August 2025 lacked symptom documentation and other required details even when residents were marked as meeting McGeer criteria. Examples reviewed by the IP and DON included residents with missing symptom information, missing dates of symptom onset, missing culture dates or results, an incorrect resident name, and a resident whose eye infection and antibiotic treatment were not reflected on the surveillance sheet. The IP and DON stated the forms were incomplete and inaccurate and that all sections should be completed unless a resident was asymptomatic.
Failure to Follow Ordered Air Mattress and Oxygen Settings
Penalty
Summary
The facility failed to ensure an air mattress was set according to the physician’s order for a resident with dementia and a stage 4 pressure ulcer to the right buttock. The resident had a physician’s order for a low air loss/alternating pressure support air mattress with the setting at 150 lbs., and the facility policy required verifying MD orders and settings according to manufacturer guidelines. On observation, the resident was found in bed with the air mattress control unit set to 200 lbs. on multiple occasions. A nurse confirmed the mattress was set to 200 lbs. rather than the ordered 150 lbs., and the Assistant Director of Nursing stated it should have been set according to the physician’s order. The facility also failed to ensure oxygen was administered according to physician’s orders for a resident with COPD, respiratory failure, and dependence on supplemental O2. The resident’s physician’s order directed O2 at 2 LPM via nasal cannula continuously, and the MAR reflected administration of 2 LPM every shift. However, surveyors repeatedly observed the resident with the oxygen concentrator set to 2.5 LPM while the nasal cannula was in place. The Unit Manager acknowledged the concentrator was set too high and adjusted it to 2 LPM, and the DON stated the nurse should check the concentrator against the physician’s orders every shift to ensure the oxygen matched the ordered LPM.
Missed COVID-19 Vaccine After Resident Consent
Penalty
Summary
The facility failed to provide the most updated COVID-19 vaccination to one resident after the resident had consented to receive it. The facility policy stated that when a current updated COVID-19 vaccine is available, it will be offered to residents unless medically contraindicated, already received, or refused, and that if a resident requests the vaccine after missed opportunities, it should be offered as soon as possible. CDC guidance reviewed by surveyors stated that staying up to date with COVID-19 vaccines is important, especially for people age 65 and older and those living in LTC facilities. Resident #11 signed consent on 1/23/25 to receive the current CDC-approved COVID-19 vaccine, but the medical record showed no COVID-19 vaccine dose since 12/17/23. Nursing progress notes from 1/23/25 through 9/4/25 did not show that the resident received the vaccine or that there was a reason it was not administered as requested. The resident's healthcare proxy was later invoked, and the family agreed with the resident receiving all vaccines. During interviews, the IP stated residents are offered COVID vaccinations on admission and annually, but said the resident had not received the requested dose because vaccinations on that floor had already been completed when the resident consented. The DON stated the resident should have received the vaccine but did not, and that it was an error that the dose was missed.
Inaccurate Wound Location Documentation
Penalty
Summary
The facility failed to ensure staff maintained accurate medical records for one resident out of a sample of 27. Resident #9 had diagnoses including dementia and a stage 4 pressure ulcer to the right buttock, and the MDS dated 7/10/25 indicated severe cognitive impairment with a BIMS score of 3 out of 15 and a stage 4 pressure ulcer. The medical record also showed the resident developed a stage 4 pressure ulcer to the right buttock in August 2024 and was followed by a consultant wound provider. Review of the consultant wound physician’s progress notes from August 2024 through September 2025 showed the stage 4 pressure ulcer was to the right buttock. However, the facility’s Interdisciplinary Wound Notes repeatedly documented the wound as being on the left hip or left ischium, including entries from 6/10/25 through 9/2/25. During interview, the ADON stated she completed weekly wound rounds and documented wounds in the medical record, acknowledged that the notes reflected a left hip wound instead of the right buttock wound, and said she was not aware her documentation was inaccurate.
Inadequate Supervision Leads to Multiple Falls and Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions for a resident identified as a high fall risk, who was also on anticoagulant medication. This resident experienced five falls within a month, one of which resulted in a subarachnoid hemorrhage. The facility's Fall Management Program required a systematic approach to prevent falls, including individualized interventions based on assessments and clinical conditions. However, despite being identified as high risk, the resident's care plan and interventions were not adequately updated or implemented to prevent these falls. The resident, admitted in May 2024, had severe cognitive impairment, a history of repeated falls, and was on multiple medications, including anticoagulants. The resident's fall risk assessment indicated a high risk for falls, and referrals to physical and occupational therapy were deemed appropriate. Despite this, the resident experienced multiple falls, some unwitnessed, and the interventions in place, such as encouraging the use of a walker and providing supervision, were not effectively executed by the staff. Interviews with staff revealed inconsistencies in supervision and a lack of adherence to the care plan. The resident was often left unsupervised, leading to falls, and staff failed to ensure the resident used a walker as recommended. It was only after the resident sustained a serious injury from a fall that 1:1 supervision was implemented. The facility's failure to provide adequate supervision and update care plans in a timely manner contributed to the resident's repeated falls and subsequent injury.
Failure to Notify Resident Representative of Treatment Change
Penalty
Summary
The facility failed to notify the Resident Representative of a change in treatment for a resident who had a significant medical event. The resident, who had severe cognitive impairment and was on anticoagulant therapy with Lovenox for a splenic infarct, experienced a fall that resulted in a subarachnoid hemorrhage. Following this incident, the Nurse Practitioner ordered the discontinuation of the anticoagulant medication due to the increased risk of intracranial hemorrhage associated with falls while on such medication. Despite the facility's policy requiring prompt notification of the physician, resident, and family regarding changes in condition, the medical record did not indicate that the Resident Representative was informed of the discontinuation of Lovenox. During interviews, the Resident Representative confirmed they were not notified, and the Unit Manager acknowledged that while she usually documents such notifications, she may have missed informing the Resident Representative in this instance.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to document a comprehensive discharge summary for a resident, identified as Resident #88, who was discharged to an Assisted Living Facility. The discharge paperwork was missing critical information, including the date and time of admission and discharge, admitting diagnosis, a brief history of the nursing home stay, the resident's condition at the time of discharge, discharge destination, final diagnosis, prognosis, date, and physician signature. This lack of documentation was identified during a review of the resident's medical record and was confirmed through staff interviews. Interviews with facility staff, including a Unit Manager, Social Worker, and the Director of Nurses, revealed that the discharge process involved printing a Continuity of Care Document and reviewing it with the resident or their representative. However, no additional assessments or observations were completed, and the discharge plan of care was not finalized at the time of discharge. The physician did not complete the discharge summary and recapitulation, and there was a belief that the physician had approximately 30 days to complete this documentation, which contributed to the deficiency.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary psychotropic medications. For one resident, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment in a timely manner, as required by standards of practice. This resident, who was admitted with diagnoses including major depressive disorder, psychosis, and unspecified dementia, was receiving an antipsychotic medication regularly. The last AIMS assessment was completed in September 2023, but the subsequent assessment due in March 2024 was not conducted. For another resident, the facility did not limit the use of as-needed (PRN) antidepressant medication to 14 days or provide a documented clinical rationale for its continued use beyond this period. This resident, admitted with diagnoses including dementia with behavioral disturbance and anxiety, had PRN orders for Trazodone that were not re-evaluated or documented with a clinical rationale for continued use. The PRN Trazodone was administered several times from March to May 2024, but there was no indication of an evaluation or clinical rationale documented in the medical record. Interviews with facility staff, including the Unit Manager and Director of Nursing, confirmed the lack of timely AIMS assessments and the absence of documentation for the PRN Trazodone orders. The facility's policies on psychotropic medication management and AIMS assessments were not adhered to, resulting in these deficiencies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,048 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wrentham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Serenity Hill Nursing Center | 1.7 mi | ★★★★★ | 18 | 0 |
| The Gardens At Cedarwood | 3.3 mi | ★★★★★ | 0 | 0 |
| Mount St Rita Health Centre | 5.2 mi | ★★★★★ | 8 | 0 |
| Madonna Manor Nursing Home | 5.5 mi | ★★★★★ | 6 | 0 |
| Medway Country Manor Skilled Nursing & Rehabilitat | 7.9 mi | — | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alliance Health At Maples.
100% money-back within 48 hours.
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.