Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Beaumont Rehab & Skilled Nursing Ctr - Northboro during CMS and state inspections, most recent first.
Dietary staff failed to change gloves and perform hand hygiene when moving between tasks and areas in the kitchen, including after handling dirty trays and utensils, resulting in improper food handling during meal service. The Food Service Director confirmed that required protocols for glove use and handwashing were not followed.
Staff did not consistently use required PPE, such as gowns and gloves, during high-contact care activities for residents on Enhanced Barrier Precautions, including changing linens and providing denture care. A resident with wounds and another with a PICC line received care without staff adhering to the facility's EBP policy, as staff either omitted gowns or failed to change gloves and perform hand hygiene as required.
A resident with dementia and high risk for pressure ulcers was found repeatedly lying on a deflated air mattress that was not functioning due to being plugged into a non-working outlet. Despite physician orders and documentation indicating the mattress was checked every shift, surveyor observations and staff interviews confirmed the mattress was not operational and required monitoring was not performed.
A resident with severe cognitive impairment was handled roughly by a CNA, as witnessed by an Activity Aide, who failed to report the incident immediately. The incident was only reported the following day by a family member, leading to an investigation and the CNA's suspension and termination.
The facility failed to have an RN on duty for at least eight consecutive hours on four days, as required. This was confirmed through a review of the PBJ Report and interviews with the facility Administrator, Facility Scheduler, and DON. The absence of an RN placed all residents at risk for unmet clinical needs.
The facility failed to ensure that Advance Directives were accurate for two residents. One resident's MOLST form was signed by someone other than the resident or the appointed HCP before the HCP was invoked. Another resident's MOLST form was signed by someone other than the resident or the appointed HCP, despite the resident being cognitively intact at the time.
The facility failed to ensure privacy and confidentiality for a cognitively impaired resident who was observed naked and attempting to dress in their bedroom. Staff members did not take appropriate actions to cover the resident or draw the privacy curtain, leaving the resident exposed to anyone looking into the room.
The facility failed to provide necessary dining assistance to two residents with dementia, leading to difficulties in accessing and consuming their meals. Staff did not intervene in a timely manner, leaving the residents struggling to eat.
A resident with a history of malignant neoplasm of the hard palate and requiring a pureed diet was able to consume regular textured food from another resident's meal tray due to inadequate supervision during meal time. Staff were either assisting other residents or not in the immediate vicinity, leading to the resident eating food that could potentially cause health issues.
The facility failed to monitor gastric residuals for a resident with a G-tube, as required by their policy. The resident, admitted with cerebral infarction and dysphagia, did not have Physician's orders to check residuals until several days after admission. The Unit Manager confirmed that the policy was not followed.
The facility failed to provide appropriate pain management for a resident with terminal cancer and mild cognitive impairment. Despite physician orders for pain assessments every shift, the facility did not consistently assess or document the resident's pain levels, leading to unmanaged pain and incomplete administration of prescribed pain medication.
The facility failed to perform trauma assessments at the time of admission for two residents with Dementia and Depression, leading to a deficiency in trauma-informed care. The Social Worker confirmed that trauma assessments were not completed if no history of trauma was identified, contrary to the facility's policy.
The facility failed to securely store and administer medications for a resident with moderate cognitive impairment. Medications were left unattended at the resident's bedside, contrary to facility policy and without proper assessment for self-administration.
Failure to Follow Sanitation and Food Handling Practices in Kitchen
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices in the main kitchen, as observed during a breakfast meal service. Dietary staff were seen handling food items and food trays, then moving around the kitchen and touching various surfaces without changing gloves or performing appropriate hand hygiene. Specifically, one staff member handled both clean and dirty trays and continued to serve food without changing gloves or washing hands, despite stepping away from the serving line and handling potentially contaminated items. Another staff member also failed to change gloves or wash hands after leaving the serving line to retrieve a utensil and then returning to serve food. Facility policies required that gloves be changed and hands washed after handling soiled items, after removing gloves, and when moving between different tasks or areas, but these procedures were not followed. The Food Service Director confirmed during interviews that the staff did not comply with the required hand hygiene and glove use protocols as outlined in the facility's policies. No information about specific residents or their medical conditions was provided in the report.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols for residents on Enhanced Barrier Precautions (EBP), as observed during multiple care activities. One resident, admitted with an open abdominal wound and atherosclerosis with ulceration, had physician orders for EBP, including the use of gowns and gloves during high-contact care such as changing linens. A CNA was observed removing soiled linens and handling clean linens for this resident while wearing gloves but not a gown, and failed to remove gloves or perform hand hygiene before exiting the room to obtain clean linens. The CNA acknowledged awareness of the EBP order but did not follow the required protocol, and later admitted she should have worn a gown and changed gloves as indicated by the signage and orders. Further observations revealed another CNA entering a room with EBP signage to perform denture care for a resident with a PICC line. The CNA donned gloves but not a gown, handled the resident's dentures, and performed hand hygiene only after completing the task. The CNA stated she was unaware of the specific reason for the precautions and did not believe a gown was necessary for denture care. Facility leadership, including the unit manager and CNO, confirmed that gowns and gloves were required for these high-contact activities under the facility's EBP policy. The facility's policy on EBP, dated 4/6/23, specifies that gowns and gloves must be used during high-contact care activities for residents with wounds or indwelling devices, regardless of MDRO status. Examples of such activities include dressing, bathing, transferring, providing hygiene, changing linens, and wound care. The observed failures to use appropriate PPE and perform hand hygiene as required by policy and physician orders resulted in a deficiency related to infection control practices.
Failure to Maintain Functioning Air Mattress for Pressure Relief
Penalty
Summary
A deficiency occurred when a resident with significant cognitive impairment, total dependence for activities of daily living, and at risk for pressure ulcers was not provided with a functioning air mattress as ordered by the physician. The air mattress, intended to provide pressure relief, was observed on multiple occasions to be deflated and not operating because it was plugged into a non-functioning electrical outlet. Despite physician orders and care plan interventions specifying the use of an air mattress and regular monitoring for comfort every shift, the mattress remained non-operational over at least two days of surveyor observation. Documentation indicated that staff were recording daily checks of the air mattress for comfort on the Medication Administration Record, but direct observation by the surveyor revealed the mattress was not inflated and the power was off during these checks. Interviews with nursing staff and the DON confirmed that the mattress was not functioning and that required checks had not been properly performed, resulting in the resident not receiving the prescribed pressure-relieving therapy.
Failure to Report Abuse Incident Immediately
Penalty
Summary
The facility failed to ensure that staff implemented and followed their abuse policy when an Activity Aide witnessed a staff member handle a resident in a potentially abusive manner but did not report the incident immediately. The incident occurred on 7/22/24 when the Activity Aide saw a CNA push down on the resident's shoulders in a rough manner as the resident attempted to stand in the activity room. The resident involved had severe cognitive impairment, requiring substantial assistance for transfers and ambulation, and had a care plan indicating the need for staff to anticipate and meet his or her needs. The incident was not reported until the following day, 7/23/24, when a family member who witnessed the event reported it to the facility. The Director of Nurses confirmed that the Activity Aide should have reported the incident immediately to administration. An investigation was initiated on 7/23/24, and the CNA involved was suspended and later terminated. The facility's policy required immediate reporting of any witnessed or known abuse, which was not adhered to in this case.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility did not have an RN working for eight consecutive hours on four days between 10/1/23 and 12/31/23. This deficiency was identified through a review of the Fiscal Year Quarter One Payroll Based Journal (PBJ) Report, which indicated no RN was present for the required hours on 10/1/23, 10/29/23, 11/12/23, and 12/3/23. Interviews with the facility Administrator, Facility Scheduler, and Director of Nurses (DON) confirmed the absence of an RN on these dates. The facility had no nurse staffing waivers in place during this period, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing.
Failure to Ensure Valid Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were accurate for two residents. For one resident, the MOLST form was signed by someone other than the resident or the appointed Health Care Proxy (HCP) before the HCP was invoked. The Director of Nurses (DON) confirmed that the MOLST form was not valid and should have been updated upon the resident's admission to the facility. The resident had been admitted with vascular dementia and was cognitively impaired, as indicated by the Minimum Data Set (MDS) assessment. For another resident, the MOLST form was also signed by someone other than the resident or the appointed HCP. The resident was cognitively intact at the time of admission, as evidenced by a BIMS assessment score of 14 out of 15. The DON acknowledged that the MOLST form was invalid because it had been signed by verbal authorization of a person who was not the resident's HCP. The resident had been admitted with a diagnosis of malignant neoplasm, and the HCP had been invoked after the MOLST form was signed.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to provide privacy and confidentiality for Resident #27, who was observed naked and attempting to dress in their bedroom. Despite being cognitively impaired and unable to complete the Brief Interview for Mental Status (BIMS) exam, the resident was left exposed. On 5/7/24, the surveyor observed the resident naked in their wheelchair from the bedroom doorway. Nurse #1, who was nearby, did not assist the resident or ensure their privacy by drawing the curtain or closing the door. Similarly, CNA #2 entered the room to obtain an item for the resident's roommate but did not cover the resident or draw the privacy curtain, leaving the resident exposed to anyone looking into the room. Interviews with the staff confirmed the oversight. Nurse #1 acknowledged that the resident should have been covered or the privacy curtain drawn. CNA #1 stated that she would have covered the resident with a sheet if she had seen them naked from the hallway. The Unit Manager also confirmed that the staff should have covered the resident when exposed. CNA #2 admitted to seeing the resident naked and informed the CNA on the resident's assignment but did not take any action to cover the resident or ensure their privacy.
Failure to Provide Dining Assistance
Penalty
Summary
The facility failed to provide necessary assistance during dining service for two residents, leading to a risk of reduced nutritional intake. Resident #54, who was diagnosed with dementia and required setup/clean-up assistance for eating, was observed struggling to open food containers and access meal items. Despite the resident's visible difficulty, staff did not intervene in a timely manner, leaving the resident unable to consume his/her meal properly. The resident was seen attempting to open a milk carton and eat with fingers, but no staff were present to assist until much later, resulting in the resident pushing away from the table without having eaten adequately. Similarly, Resident #61, who had dementia and Parkinson's disease and required setup assistance for eating, was observed struggling to eat his/her breakfast. The resident attempted to pick up pancakes with a spoon and brought an empty spoon to his/her mouth multiple times. The resident also scooped across the tablecloth and held multiple utensils without successfully eating. Staff did not provide the necessary assistance until much later, leaving the resident without proper access to his/her meal. Interviews with staff revealed that they were aware of the residents' needs for assistance but failed to provide timely help. The MDS Nurse and Unit Manager acknowledged that staff should have offered to open food items and assist residents who showed difficulty in accessing their meals. The lack of timely intervention and assistance during meal times for these residents highlights a deficiency in the facility's dining service and care practices.
Inadequate Supervision During Meal Time
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident during meal time, leading to the resident consuming food that was not consistent with their prescribed diet. The resident, who had a history of malignant neoplasm of the hard palate and required a pureed diet due to swallowing difficulties, was able to obtain and eat regular textured food from another resident's meal tray. This incident occurred despite the facility's policy to adhere to therapeutic diets and provide proper assistance to residents as needed. The resident was observed in the dining room seated next to another resident. After the other resident left the table, staff returned the meal tray, which included a partially eaten breakfast sandwich and a muffin. The resident, who had finished their own pureed meal, was left unsupervised and subsequently took a bite of the muffin from the other resident's tray. The staff present in the dining area were either assisting other residents or not in the immediate vicinity, leading to a lack of supervision for the resident. Interviews with facility staff revealed a lack of awareness and understanding of the resident's dietary needs. The Dementia Special Care Unit Program Director acknowledged the resident's tendency to wander and pick up items belonging to others but could not speak to the level of supervision provided during meals. The Unit Manager incorrectly believed the resident was on a regular diet, and the Speech Language Pathologist confirmed that the resident should remain on a pureed diet due to the risk of complications from consuming regular textured food. The failure to provide adequate supervision and adhere to the resident's dietary requirements resulted in the resident consuming food that could potentially cause health issues.
Failure to Monitor Gastric Residuals for G-Tube
Penalty
Summary
The facility failed to provide appropriate care, services, and monitoring of a gastrostomy tube (G-tube) for a resident. The staff did not obtain Physician's orders to check for gastric residual volume, which is necessary to identify and prevent complications associated with enteral feeding. The facility's policy required checking residuals once per shift or per Physician order to minimize potential complications such as vomiting, distention, and aspiration. However, this was not done for the resident from the time of admission until the first day of the Department of Public Health (DPH) survey. The resident was admitted with diagnoses including cerebral infarction and dysphagia, necessitating the use of a G-tube. The care plan indicated that enteral feeding management should be per Physician's orders. Despite this, the Medication Administration Record (MAR) did not show any orders or checks for gastric residuals until several days after admission. During an interview, the Unit Manager acknowledged that the Physician's order to check for gastric residuals should have been in place upon admission, as per facility policy, but it was not followed.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #28, who was admitted with diagnoses including malignant neoplasm of the reproductive system and mild cognitive impairment. Despite physician orders requiring pain assessments every shift using a numeric pain scale, the facility did not consistently assess or document the resident's pain levels. Interviews with the resident and nursing staff revealed that the resident experienced significant pain and did not always receive the prescribed pain medication. The resident reported instances where only half of the prescribed pain medication was administered, leading to unmanaged pain levels that affected daily activities. Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from December 2023 to May 2024 showed no evidence of documented pain assessments using the numeric pain scale. Nursing staff confirmed that the pain assessments were not documented as required, and the Unit Manager acknowledged that the physician's order had been entered incorrectly into the computer system. This lack of proper documentation and assessment resulted in the facility's failure to manage the resident's pain effectively, as per professional standards and the facility's own pain management policy.
Failure to Perform Trauma Assessments at Admission
Penalty
Summary
The facility failed to perform trauma assessments at the time of admission for two residents, leading to a deficiency in trauma-informed care. Resident #45, admitted in June 2023 with diagnoses of Dementia and Depression, had no evidence in their clinical record of being assessed for a history of trauma. The Social Worker (SW) confirmed during an interview that a trauma assessment would not have been completed if no history of trauma was identified, indicating a lapse in the facility's policy implementation. Similarly, Resident #79, admitted in May 2023 with diagnoses of Dementia and Major Depressive Disorder, also had no evidence of a trauma assessment in their clinical record. The SW acknowledged responsibility for screening all residents for trauma history upon admission but admitted that there was no evidence that Resident #45 and Resident #79 had been screened for trauma since their admission. This failure to conduct trauma assessments is contrary to the facility's policy, which mandates that all residents be assessed for trauma history upon admission.
Failure to Securely Store and Administer Medications
Penalty
Summary
The facility failed to ensure that medications were stored and administered in a secure and safe manner for one resident. Specifically, medications were left unattended in a medication cup at the bedside of a resident who was moderately cognitively impaired. The resident had diagnoses including arthrosclerosis of arteries in both legs, atrial fibrillation, mild cognitive impairment, and dysphagia. The facility's policy required medications to be stored safely and securely, and for medications to be administered in a safe and effective manner. The resident had not been assessed as a candidate for self-administration of medications. On the day of the survey, a surveyor observed a small plastic cup containing multiple pills on the bedside table next to the resident. The resident stated that staff usually leave medications on the bedside table for him/her to take independently. A nurse confirmed that she left the medications at the bedside because the resident likes to take them independently, but acknowledged that she should have watched the resident take the medications and should not have left them unattended. The unit manager confirmed that the resident had not been assessed to safely administer his/her own medications and that the nurse should not have left medications at the bedside unattended.
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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 Northborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alliance Health At Coleman | 0.6 mi | ★★★★★ | 10 | 0 |
| Shrewsbury Rehabilitation And Nursing At Southgate | 2.8 mi | ★★★★★ | 6 | 0 |
| Beaumont Rehab & Skilled Nursing Ctr - Westboro | 3.2 mi | ★★★★★ | 10 | 0 |
| Westborough Healthcare | 3.4 mi | ★★★★★ | 6 | 0 |
| Marlborough Hills Rehabilitation & Health Care Cen | 4.2 mi | ★★★★★ | 1 | 0 |
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