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 Rosewood during CMS and state inspections, most recent first.
Bare-hand contact with ready-to-eat food during meal assistance. Staff on two units handled residents' toast and a sandwich with bare hands while providing feeding assistance and tray set-up, including buttering and jelling toast and handing food back to residents to eat. Nurse #2, the DON, and the Administrator stated staff should not use bare hands when handling ready-to-eat food.
Failure to complete a baseline care plan within 48 hours of admission for a resident with dementia and repeated falls. The medical record did not show a baseline care plan, and staff stated the plan should have been completed within 48 hours and would identify the assistance the resident required for care. A progress note also documented that the resident was found on the floor.
Oxygen Given Without Physician Order: A resident with COPD and dependence on supplemental O2 was observed receiving continuous O2 via nasal cannula at 3 L/min even though the chart contained no active physician order for oxygen. Nursing notes and an NP visit note documented ongoing oxygen use, and staff interviews confirmed the resident had been receiving supplemental oxygen throughout the stay without an order in place.
Medication administration errors resulted in an 8.82% error rate, above the allowed threshold. A nurse gave one resident an incorrect dose of vitamin D and an insufficient amount of polyethylene glycol, and another nurse administered the wrong eye drops to a resident with dementia. The facility policy required the five rights and triple-check verification, but the observed administrations did not match the physician orders.
Inaccurate PICC Site Documentation: A resident with a PICC line had a dressing saturated with bright red blood and bruising at the insertion site, yet an RN documented the site as CDI on the MAR. The resident’s orders required the PICC site to be assessed and documented every shift, and the care plan noted bleeding/bruising risk related to anticoagulant use for atrial fibrillation. The Unit Mgr and DON stated the bleeding should have been recognized and documented accurately.
A resident with a non-pressure wound on the leg did not receive the prescribed wound care treatments as recommended by the Wound Physician and Wound Clinic. The facility's Treatment Administration Records showed discrepancies in the treatment plan, and interviews with staff revealed a breakdown in communication and process for implementing orders. This resulted in the resident not receiving the appropriate wound care, compromising the healing process.
The facility failed to serve food at a safe and appetizing temperature, with residents reporting cold and unpalatable meals. Test trays confirmed that food items were served below the expected temperature of 135°F, with the RD and FSD acknowledging the deficiency.
A facility failed to follow infection control measures during medication preparation. An LPN touched medications with bare hands, contaminating them, and continued without sanitizing. Another LPN stored an open coffee cup in a medication cart, risking contamination. Both actions violated facility policies.
A resident, admitted for muscle weakness and post-surgery care, reported being yelled at by a CNA after using the call light. The resident, who was cognitively intact, felt upset and fearful. The incident was not reported immediately as required by the facility's policy. The Unit Manager was unaware until later, and the Administrator initiated a report to the state agency after learning of the allegation.
A resident with epilepsy and dementia was not provided with required safety interventions, including a motion detector alarm for fall prevention and seizure pads on bed rails. Staff were unaware of these care plan requirements, leading to their non-implementation, as confirmed by the ADON.
A resident with macular degeneration, requiring substantial assistance with bathing, did not receive scheduled weekly showers over a two-month period. Despite being cognitively intact and expressing a desire for showers, the resident received only one shower, with no documentation of refusal. Staff interviews confirmed the resident's need for assistance, but they could not recall the last shower provided, indicating a lapse in care according to the facility's policy.
The facility failed to maintain professional standards in catheter care for two residents. One resident's catheter drainage system was repeatedly observed touching the floor, contrary to policy, while another resident returned from the hospital with a catheter but lacked physician orders and a care plan for its management. These deficiencies indicate a significant oversight in maintaining professional standards of care.
A facility failed to limit a PRN order for alprazolam, a psychotropic medication, to 14 days as required by policy. A resident with generalized anxiety disorder received the medication without a specified stop date or duration. Despite a recommendation for re-evaluation, the physician continued the order without justification. Staff interviews confirmed the oversight.
A resident with macular degeneration had significant gaps in daily care documentation, including grooming, dressing, and transfers, over two months. Despite staff education and new flow sheets, the facility failed to maintain accurate records, as confirmed by CNAs and the Unit Manager.
Bare-Hand Contact With Ready-to-Eat Food During Meal Assistance
Penalty
Summary
The facility failed to distribute food in accordance with professional standards for food service safety by allowing staff to handle ready-to-eat food with bare hands on two of three units. The Massachusetts Food Code cited in the report states that food employees may not contact exposed, ready-to-eat food with bare hands and must use utensils, deli tissue, tongs, single-use gloves, or dispensing equipment. In health care facilities, food employees include staff who set up trays for patients to eat and those who feed or assist patients in eating. On 1/21/26 at 8:34 A.M., a staff member assisting a resident with feeding in the second-floor dining room touched her mask with her bare hand, then used her bare hands to pick up the resident's toast, butter it, and place it back on the resident's plate. At 8:37 A.M., the same staff member again used her bare hand to pick up the ready-to-eat toast and handed it to the resident to eat. Later that day at 12:55 P.M., another staff member feeding a resident in the second-floor dining room picked up a half sandwich with a fork, but when it fell onto the resident's lap, the staff member picked it up with bare hands and handed it to the resident to eat. On 1/23/26 at 8:39 A.M., a staff member providing meal tray set-up assistance in the third-floor dining room picked up both slices of a resident's ready-to-eat toast with bare hands, applied jelly, and placed the toast back on the resident's plate. Nurse #2, the DON, and the Administrator each stated that staff should not use bare hands when handling ready-to-eat food.
Failure to Complete Baseline Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for one resident out of a sample of 26. The facility policy titled "Baseline Care Plan," dated 5/15/22, stated that a baseline care plan is developed within 48 hours of admission and includes instructions needed to provide effective and person-centered care that meets professional standards of quality care. Resident #124 was admitted in October 2025 with diagnoses including dementia and repeated falls. A progress note dated 11/1/25 at 5:00 A.M. documented that the resident had been found on the floor, and review of the medical record did not show a baseline care plan. During interviews, the Unit Manager stated that a baseline care plan should be completed within 48 hours of admission and would show what kind of assistance the resident would require for care. The DON also stated that the baseline care plan should have been completed within 48 hours of admission and that nurses were responsible for initiating it.
Oxygen Given Without Physician Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for a resident admitted with COPD with acute exacerbation and dependence on supplemental oxygen. Review of the resident’s current active physician and telephone orders showed no order for continuous oxygen, and the discontinued orders also did not show an oxygen order for this admission. Despite the lack of an active order, the resident was observed receiving oxygen via nasal cannula at 3 liters per minute on multiple occasions, and nursing progress notes dated 1/14/26 through 1/20/26 documented that the resident was receiving supplemental oxygen. The SNF initial NP visit note dated 1/16/26 stated the resident had a history of COPD and was receiving oxygen nightly and as needed during the day, and that the resident was wearing oxygen as prior to admission. Staff interviews confirmed the resident was receiving supplemental oxygen continuously, that staff frequently checked to ensure the nasal cannula was on, and that the resident used a portable oxygen tank when leaving the room. Nurse #2, Unit Manager #2, the NP, and the DON each stated they would expect a physician order to be in place before oxygen was administered, and they acknowledged the resident did not have an active order for the oxygen being provided.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. Based on observations, interviews, and record reviews, two of four nurses observed made 3 errors in 34 medication opportunities, resulting in an 8.82 percent medication error rate. The facility policy required the five rights of medication administration and a triple check process, including verifying the medication against the MAR when selected, when the dose is removed, and after preparation. For one resident with vitamin D deficiency and dementia, the nurse administered cholecalciferol 400 units instead of the ordered 1,000 units and gave polyethylene glycol at an insufficient amount by filling the bottle cap below the 17 gram indicator line. For another resident with Alzheimer's dementia, the nurse administered Systane eye drops even though the physician's order and pharmacy fill status note indicated GenTeal Tears Moderate PF should have been used. The nurse stated she was unsure the Systane drops were correct because the active ingredients did not match the order, and the DON stated the eye drops should have been administered according to the physician's order.
Inaccurate PICC Site Documentation
Penalty
Summary
The facility failed to accurately document a PICC line site assessment for one resident in a sample of 26. The resident was admitted in November 2025 with diagnoses including acute on chronic diastolic congestive heart failure, chronic kidney disease, and artificial opening of urinary tract status. The most recent MDS indicated the resident scored 13 out of 15 on the BIMS, showing the resident was cognitively intact. Facility policy required VAD assessments at least once each shift when not in use and to include drainage at a minimum. During an observation, the resident’s PICC line to the right arm had a dressing dated 1/19/26, and the insertion site had a bruise with bright red blood saturated into the dressing. The physician’s orders required the PICC site to be assessed every shift and the site condition and patency documented every shift, and the dressing changed as needed if wet, loose, soiled, or unable to inspect the insertion site. The resident’s care plan identified risk for excessive bleeding and/or bruising due to anticoagulant administration related to atrial fibrillation. Despite this, the MAR showed Nurse #5 documented the PICC site as clean, dry, and intact on the shift when the bleeding was present. The Unit Manager stated the dressing needed to be changed because of the large amount of bright red blood and that the nurse should not have documented the site as clean, dry, and intact. Nurse #5 acknowledged seeing the bleeding but said she did not think it was a big deal and should not have documented the site as clean, dry, and intact. The DON stated that if bright red blood is seen at the PICC site, the dressing should be changed and the physician notified if the resident is on an anticoagulant, and that nurses should document accurately when they assess a resident.
Failure to Implement Physician's Wound Care Orders
Penalty
Summary
The facility failed to implement the physician's orders related to wound care for a resident with a non-pressure wound on the right upper lateral leg. The resident, who was admitted with diagnoses including cancer and cerebrovascular accident, required specific wound treatments as recommended by the Wound Physician and Wound Clinic. However, the facility did not follow these recommendations, as evidenced by the Treatment Administration Records (TAR) which showed discrepancies in the treatment plan. The prescribed treatments, such as the use of alginate rope, Mupirocin 2%, and Superabsorbent gel fiber, were not included in the TAR, and the frequency of dressing changes did not align with the physician's orders. Interviews with the resident revealed that the wound care was not as efficient as expected, and the resident expressed concerns about the prolonged healing process. The resident's clinical care plan indicated a goal for the wound to heal without complications, but the facility's failure to adhere to the wound care recommendations compromised this goal. The Wound Physician's notes and the facility's Skin Management Program outlined specific procedures for wound care, which were not consistently followed, leading to a lack of proper treatment for the resident's wound. Interviews with facility staff, including the Nurse Practitioner and Assistant Director of Nursing, highlighted a breakdown in communication and process for implementing wound care orders. The Nurse Practitioner was unaware that the treatment orders did not match the Wound Physician's recommendations, and the Assistant Director of Nursing was not informed that the orders were not being implemented as directed. This lack of awareness and adherence to the prescribed wound care regimen contributed to the deficiency in the resident's care.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to serve food that was palatable and at a safe and appetizing temperature across all three units. During the initial tour, residents expressed concerns about the food being served cold and tasting bad. Specifically, seven residents on the first floor and one resident on the second floor reported issues with the food's temperature and quality. During a resident group meeting, a resident reiterated that the food was served cold. These observations were confirmed during test tray evaluations conducted by surveyors, which revealed that food items such as meatballs, pasta, green beans, and soup were served at temperatures below the expected minimum of 135 degrees Fahrenheit. The Registered Dietitian (RD) and Food Service Director (FSD) both acknowledged that the temperatures recorded were lower than expected. The RD stated that hot food should be at least 135 degrees Fahrenheit upon arrival to residents, with certain items like soups expected to be even hotter. The FSD indicated a goal of serving hot food at around 160 degrees Fahrenheit. Despite these expectations, the test trays showed that food temperatures were consistently below these standards, with items like meatballs, pasta, and green beans being served lukewarm or cool, and some items like raspberry sherbet melting before reaching residents.
Infection Control Breach During Medication Preparation
Penalty
Summary
The facility failed to adhere to infection control and prevention measures during medication preparation, as observed by surveyors. Nurse #2 was seen preparing medication for a resident without following proper hand hygiene protocols. She touched multiple surfaces, including medication cards, bottles, and a laptop, with her bare hands. During the preparation, she accidentally poured extra pills into a medication cup and used her bare finger to remove them, contaminating the medications. Despite acknowledging the mistake, Nurse #2 continued to prepare additional medications without sanitizing her hands or using gloves, further risking contamination. Additionally, Nurse #3 was observed storing an open coffee cup inside a medication cart, with medication bottles directly touching the cup. This practice was acknowledged by Nurse #3 and confirmed by the Regional Clinical Specialist and the Assistant Director of Nursing as inappropriate due to infection control concerns. Both incidents highlight a failure to follow the facility's policy on medication administration and infection prevention, as outlined in their guidelines.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who was admitted with diagnoses including muscle weakness and aftercare following joint replacement surgery. The resident, who was cognitively intact, reported that a CNA yelled at them after they used their call light. The incident occurred when the CNA expressed frustration about being the only one working and needing to take a break due to their diabetic condition. The resident felt upset and expressed fear about using the call light in the future. The resident informed a nurse about the incident the following morning, but the nurse's identity was not recalled. The Unit Manager was unaware of the incident until interviewed and stated she would address it. The Administrator learned of the allegation later and initiated a report to the state agency. The report highlights a failure to adhere to the facility's Abuse Prohibition Policy, which mandates immediate reporting and investigation of abuse allegations.
Failure to Implement Care Plan Interventions for Resident Safety
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident diagnosed with epilepsy and vascular dementia. The resident was identified as being at high risk for falls, with a care plan intervention requiring the use of a motion detector alarm when the resident was in their room. However, observations by the surveyor on multiple occasions revealed that the motion detector alarm was not activated, leaving the resident unattended without the necessary fall prevention measures in place. Interviews with staff, including a CNA and a nurse, indicated a lack of awareness regarding the requirement for the motion detector alarm, resulting in its non-implementation. Additionally, the facility did not implement seizure precautions as outlined in the resident's care plan. The resident, who was on medication for seizure control, had a care plan intervention to pad the side rails of their bed to prevent injury during a seizure. Despite this, the surveyor observed the resident's bed without seizure pads on the side rails on several occasions. Interviews with the CNA and nurse revealed that they were unaware of the need for seizure pads, and the necessary equipment was not present in the resident's room. The Assistant Director of Nursing confirmed that all care plan interventions should be implemented as listed in the resident's care plan. The failure to activate the motion detector alarm and apply seizure pads as required by the care plan represents a significant oversight in the facility's responsibility to ensure the safety and well-being of the resident.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate assistance with bathing for a resident who is legally blind and requires substantial assistance with daily living activities. The resident, who was admitted with a diagnosis of macular degeneration, expressed during interviews that they had not received a shower in a long time and desired one for personal cleanliness. The resident's care plan indicated a need for maximum assistance with bathing, and the facility's policy required frequent showers or baths to be scheduled and assistance provided as needed. Despite being scheduled for weekly showers, the resident received only one shower over a two-month period, with no documentation of refusal of care. Interviews with CNAs and the Unit Manager confirmed that the resident did not refuse care and required assistance with bathing tasks. However, the staff could not recall the last time the resident was given a shower, and there was no nursing documentation to indicate any refusals, highlighting a failure in adhering to the facility's policy and the resident's care plan.
Failure in Catheter Care Management
Penalty
Summary
The facility failed to maintain professional standards in managing and caring for urinary catheter devices for two residents. For Resident #105, the facility did not provide appropriate care to prevent urinary tract infections. The urinary catheter drainage system, including the tubing, was observed directly touching the floor on multiple occasions, contrary to the facility's policy that requires the drainage bag to be kept off the floor. Resident #105, who has severe cognitive impairment and is dependent on staff for mobility and toileting, was unable to adjust the height of the bed or reach the urinary catheter drainage bag without assistance. Despite the facility's policy and the resident's care plan, staff did not ensure the catheter system was elevated, as confirmed by observations and interviews with staff and family members. For Resident #71, the facility failed to implement physician orders and care plans related to the use of a catheter. Although the resident returned from the hospital with a catheter due to acute urinary retention, there were no physician orders or care plans in place for the catheter's use or care. The resident's care plans only addressed urinary incontinence and did not mention the catheter, despite the hospital discharge summary and nursing progress notes indicating the presence of a Foley catheter. Interviews with the unit manager and the Director of Nursing confirmed that they expected a resident with a catheter to have appropriate orders and a care plan. These deficiencies highlight a lack of adherence to established protocols for catheter care, potentially compromising the residents' health. The facility's failure to ensure proper catheter management and documentation for these residents indicates a significant oversight in maintaining professional standards of care.
Failure to Limit PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that the drug regimen for a resident was free of unnecessary psychotropic medications. Specifically, the facility did not limit a PRN order for alprazolam, a psychotropic medication, to 14 days as required. The order was first initiated on November 6, 2024, without a specified stop date or duration for its use. The resident, who was admitted with a diagnosis of generalized anxiety disorder, was cognitively intact and received antianxiety medication as indicated in their Minimum Data Set assessment. The facility's policy on psychotropic medication management requires PRN orders for such drugs to be limited to 14 days unless the prescribing physician provides a documented rationale for extending the order. Despite a consultant pharmacist's recommendation to re-evaluate the PRN alprazolam after 14 days, the physician's response was to continue the medication without providing medical justification or specifying the duration. Interviews with facility staff, including the Unit Manager and Assistant Director of Nursing, confirmed that the PRN order should have included a stop date and been re-evaluated, but these steps were not taken.
Documentation Deficiency for Resident Care
Penalty
Summary
The facility failed to complete daily documentation for a resident, identified as Resident #107, who was admitted with diagnoses including macular degeneration. The resident's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 15, showing cognitive intactness, and required assistance for bathing tasks. However, a review of the Activities of Daily Living (ADL) documentation for December 2024 and January 2025 revealed significant gaps in documentation. Specifically, there were numerous missing entries for grooming, dressing, bladder care, feeding, toileting, and transfers, with December showing 60 out of 93 opportunities missing for several tasks and January showing 37 out of 63 opportunities missing. Interviews with Certified Nursing Assistants (CNAs) and the Unit Manager confirmed that all care provided should be documented on all shifts. The Assistant Director of Nursing mentioned that the facility had recently implemented new flow sheets and conducted staff education on the importance of documenting care provided on all shifts. Despite these efforts, the documentation deficiencies persisted, indicating a failure in maintaining accurate and complete medical records for the resident.
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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 Peabody
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Care At Brooksby Village | 1.1 mi | ★★★★★ | 12 | 0 |
| Care One At Peabody | 2.2 mi | ★★★★★ | 10 | 0 |
| Pilgrim Rehabilitation & Skilled Nursing Center | 2.3 mi | ★★★★★ | 5 | 0 |
| Jeffrey & Susan Brudnick Center For Living | 2.5 mi | ★★★★★ | 1 | 0 |
| Hathorne Hill Rehabilitation And Healthcare Center | 2.5 mi | ★★★★★ | 14 | 0 |
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