Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 - Westboro during CMS and state inspections, most recent first.
Medication administration errors occurred for two residents. One resident with dementia, Parkinson’s disease, and mood/behavior concerns had a Seroquel order that was not transcribed to the MAR for days, resulting in missed doses until the error was discovered after worsening behaviors. Another resident with ESRD and HTN received Metoprolol Tartrate and Midodrine outside the physician-ordered SBP parameters, and the DON and UM confirmed the meds were given or held contrary to the orders.
Food Served at Unsafe Temperatures: The facility failed to serve lunch meals at safe and appetizing temperatures on two units. Residents reported that food often arrived cold, trays were passed out slowly, and staff sometimes offered to reheat meals in the microwave. Surveyors’ test trays showed hot items such as corned beef, carrots, and potatoes were served below the FSD’s stated minimum temperature, and a cold dessert was also not kept cold enough.
Failure to Promptly and Adequately Resolve Resident Grievances: Two residents had grievances that were not adequately investigated or resolved. One resident, who was cognitively intact and bedbound with MS and paraplegia, reported being left on a bed pan for an extended period after repeated calls for help, but the grievance form lacked investigation details, findings, and confirmation of the concern. Another resident with severe cognitive impairment, hemiplegia, and a mechanically altered diet had missing lower dentures; the grievance was documented as resolved even though records continued to show only upper dentures being used and no follow-up occurred until surveyor review.
A resident with dementia, osteopenia, osteoarthritis, and dependence for transfers had a care plan requiring a Hoyer lift with two assists. Staff did not follow the transfer plan: one CNA moved the resident from a recliner to bed without a lift or second staff member, and another CNA used the lift alone. The resident was later sent to the hospital with findings consistent with a right femur fracture.
Failure to Invite Residents to Care Plan Meetings: Three residents with invoked HCPs and intact cognition were not shown to have been invited to their care plan meetings, and the records lacked documentation that their participation was not practicable. The facility policy and resident guide stated residents are to be informed of and participate in care planning, but interviews and record review showed the residents were unaware of the meetings or could not recall being invited, while the MDS Nurse and Administrator acknowledged they should have been invited.
Two residents with indwelling urinary catheters received deficient care when staff failed to follow a physician order for the correct catheter size for one resident and allowed another resident’s drainage bag to rest on the floor. Staff observations and interviews confirmed the catheter size mismatch and the infection control concern with the bag placement, despite orders for routine catheter care and guidance that drainage bags should remain off the floor.
Failure to Use EBP During High-Contact Care: Staff provided ADL care to a resident with an indwelling urinary catheter while wearing gloves but not a gown, and another staff member entered the room without observed hand hygiene and also provided care without a gown. The resident’s care plan, MDS, and physician’s orders required EBP, and the posted room sign directed staff to clean hands and wear gown and gloves for high-contact care activities.
A resident on hospice with multiple comorbidities who required set-up assistance for meals was served a cup of coffee that had been reheated in a microwave without the CNA checking the temperature as required by facility policy. While the CNA was removing the resident’s meal tray and placing the hot coffee on the tray table, the table was bumped and the coffee spilled onto the resident’s upper thighs, resulting in first- and second-degree burns that required daily wound treatment. Interviews and record review confirmed that reheating guidelines and posted microwave safety instructions, including use of a thermometer to verify beverage temperature, were not followed.
A facility failed to assess the use of an abdominal binder as a physical restraint for a resident with nephrostomy tubes. The resident, who had acute kidney failure and dementia, used the binder to secure drain tubes. However, no assessment was documented to determine if the binder could be easily removed, as required by the facility's policy. Observations showed the resident was unsteady, and interviews confirmed the lack of assessment, which was acknowledged by the DON.
A facility failed to update a Level I PASARR for a resident who developed new psychiatric symptoms and was diagnosed with PTSD. Initially, the resident did not require a Level II evaluation, but subsequent assessments showed worsening behavior and new diagnoses, including PTSD, necessitating a review. Despite these changes, the facility did not resubmit the PASARR, and staff confirmed the oversight, noting the absence of a PASARR policy.
A facility failed to create a Trauma Informed Care Plan for a resident with PTSD. Despite the resident's history of depression and anxiety, and a new PTSD diagnosis, no assessment or care plan was developed. Staff interviews revealed a lack of communication and documentation regarding the resident's PTSD, leading to inadequate care planning.
A facility failed to safely administer Furosemide to a resident with heart failure and hypertension. The ordered 10 mg dose was not delivered from the pharmacy, leading staff to improperly use a 20 mg tablet, breaking it in half to administer the dose. This practice violated facility policy, which discourages splitting unscored tablets due to dosing inaccuracies. The DON confirmed the order never reached the pharmacy, and the nurse admitted to borrowing medication from another resident.
A facility failed to transmit a discharge MDS assessment for a resident with dementia within the required 14-day timeframe. The assessment was completed but not sent to IQIES, as confirmed by the MDS Nurse.
Medication Administration Errors With Psychotropic and Blood Pressure Medications
Penalty
Summary
Resident #11, who was admitted with diagnoses including dementia, Parkinson’s disease, and adjustment disorder with depressed mood, had a physician order written for Seroquel 12.5 mg by mouth daily at 2:00 P.M. The order was not transcribed onto the February 2026 MAR, and the March 2026 MAR showed the order was not posted until 3/16/26, 19 days after the physician order was written. Nursing staff identified the issue only after the resident’s behaviors worsened and the NP reviewed the medications. During interviews, Nurse #2 stated Resident #11 had a history of behaviors, anxiety, and restlessness, and that the NP discovered the written Seroquel order from 2/24/26 had never been transcribed. UM #2 confirmed the transcription error and stated the order should have been transcribed on the day it was written but was not until 3/16/26. The DON also stated the order should have been posted to the MAR on 2/24/26 and that the failure resulted in several days of missed doses. Physician #1 stated the resident would have benefited from receiving the Seroquel as ordered to treat worsening behaviors. Resident #6, who had diagnoses including ESRD and hypertension, had physician orders for Metoprolol Tartrate 50 mg twice daily with instructions to hold for SBP lower than 110, and Midodrine 10 mg with instructions to hold if SBP was greater than 120. Review of the MARs showed Metoprolol Tartrate was administered on multiple occasions when SBP was below 110, and was held once when SBP was 110. The MAR also showed Midodrine was administered when SBP was 123 and 124. Nurse #3, UM #2, and the DON all confirmed the medication administration did not follow the ordered blood pressure parameters.
Food Served at Unsafe Temperatures
Penalty
Summary
The facility failed to provide food at safe and appetizing temperatures for lunch meal carts on two units, including the [NAME] Unit and the [NAME] Unit. The facility policy titled Food: Quality and Palatability stated that food will be palatable, attractive, and served at a safe and appetizing temperature, and that food and liquids are to be prepared and served in a manner that meets residents’ needs. Resident Council Meeting Minutes from 2025-2026 documented repeated complaints about cold food, including cold vegetables, melted ice cream, cold soups, cold French fries, cold toast, and eggs that were cold, with no resolution documented in some meetings. During observations on 3/12/26, multiple residents on the [NAME] Unit told surveyors that food arrived cold, trays took a long time to be passed out, and staff sometimes offered to heat food in the microwave. On 3/17/26, surveyors completed two lunch meal test trays after all resident trays were passed. One tray on the [NAME] Unit showed corned beef and gravy at 105 degrees F, minced carrots at 108 degrees F, and butterscotch pudding at 70 degrees F. Another tray on the [NAME] Unit showed corned beef at 100 degrees F, boiled carrots at 87 degrees F, and boiled potatoes at 90 degrees F. The Food Service Director stated that hot items should have been served at least 120 degrees F and cold items below 50 degrees F, and the trays did not meet those temperatures.
Failure to Promptly and Adequately Resolve Resident Grievances
Penalty
Summary
The facility failed to make prompt efforts to adequately resolve grievances for two residents. The grievance policy stated that complaints or grievances regarding care or lack of care, lost possessions, and similar concerns would be heard, investigated promptly, and resolved whenever possible. For one resident, who had multiple sclerosis, paraplegia, chronic pain, anxiety disorder, and was cognitively intact, the concern involved being left on a bed pan for an extended period during the overnight shift after calling for assistance. The resident reported waiting 30 minutes to have the bed pan placed and more than 30 minutes to have it removed, and said he/she eventually called 911 after staff did not respond. The grievance form completed by the Administrator for this resident was incomplete and did not identify the time or location of the event, did not include the response section, and did not document steps taken to investigate the complaint, pertinent findings or conclusions, or whether the grievance was confirmed or not confirmed. During interview, the Administrator stated she did not speak with the resident and did not conduct an investigation regarding the concern. A Unit Manager stated she was aware the resident had called 911 about personal care concerns, but she did not provide an apology and was not aware the resident wanted one. For the second resident, who had a history of cerebral infarction, Type 2 diabetes, hemiplegia, severe cognitive impairment, unclear speech, dependence for ADLs, weight loss, and a mechanically altered diet, the facility documented that the lower dentures were missing and later recorded the grievance as resolved. However, the resident’s record continued to show only upper dentures being placed and removed by staff, and there was no follow-up or re-filed grievance regarding the missing lower dentures until the issue was brought to the facility’s attention by the surveyor. The Unit Manager and Administrator both stated they were unaware the lower dentures were still missing and that the grievance documentation had been inaccurate.
Failure to Follow Two-Person Mechanical Lift Transfer Plan
Penalty
Summary
The facility failed to implement the resident’s person-centered care plan for transfers when Resident #70 was moved with a mechanical lift without the required two staff assists. Resident #70 was admitted with diagnoses including osteopenia, dementia, osteoarthritis, and other specified disorders of bone density and structure. The MDS indicated the resident was rarely or never understood, had long- and short-term memory problems, severely impaired decision-making, was dependent for personal hygiene, was non-ambulatory, and was dependent for transfers between bed and chair. The resident’s ADL care plan, dated 2/22/26, directed that chair-to-bed-to-chair transfers be completed with a Hoyer lift and two assists, and the Profile Care Plan Approaches also stated Hoyer with two assists, dependent. The facility policy on Safe Lifting and Movement stated that all transfers with lifts should be based on the care plan, including level of assistance and number of staff. Despite this, the record showed the resident was transferred without following the planned assistance requirements. The resident was later transferred to the hospital on 3/6/26 for findings consistent with a fracture of the right femur. During the investigation, the DON and surveyor identified that CNA #6 and CNA #7 had not transferred Resident #70 in accordance with the care plan before the injury was identified. CNA #6 stated he moved the resident from a recliner to bed on 3/3/26 without a mechanical lift or another staff member, and CNA #7 stated she transferred the resident from bed to a recliner on 3/2/26 using a mechanical lift by herself, acknowledging that lift transfers should be done with two staff members.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that three residents were invited to participate in their individual care plan meetings and failed to document any rationale for why their participation was not practicable. The deficiency involved Residents #3, #11, and #15, all of whom had invoked health care proxies, but the record did not show that the residents themselves were invited to the care plan process or that their attendance was considered impracticable. The facility policy and resident guide stated that residents are to be informed of and participate in care planning, and that residents and/or their representatives are encouraged to take part in care plan development and revisions. Resident #3 was admitted with diagnoses including anxiety, dementia, heart failure, and diabetes. The MDS assessment showed the resident was cognitively intact with a BIMS score of 14 and was able to make self understood and understand others. Care plan meetings were held without evidence that the resident was invited or present, and the record did not include documentation that participation was not practicable. During interview, the resident said he/she could not recall being invited and would like to attend if possible. Resident #11 was admitted with diagnoses including Parkinson’s disease, dementia, and weakness, and the MDS showed a BIMS score of 15 with the resident usually able to make self understood and understand others. Resident #15 was admitted with diagnoses including anxiety, weakness, and urinary retention, and the MDS showed a BIMS score of 14 with the resident able to make self understood and understand others. For both residents, care plan meetings were held without evidence of resident invitation or attendance, and the records lacked documentation that resident participation was not practicable. Interviews showed both residents were unaware of care plan meetings or could not recall being invited, and the MDS Nurse stated the residents should have been invited so they could be aware of their plan of care and have an opportunity for self-advocacy.
Urinary Catheter Care and Order Compliance Deficiencies
Penalty
Summary
The facility failed to provide appropriate care related to indwelling urinary catheters for two residents. Resident #93, who had diagnoses including urinary retention and severe cognitive impairment, had physician orders for a 14 Fr silicone catheter with a 10 mL balloon and monthly changes. However, the resident was observed with a 16 Fr catheter and 10 mL balloon, and the clinical record did not contain an order for that catheter size. Nursing documentation showed the catheter had been replaced after leaking, and staff interviews confirmed the catheter size did not match the physician order. Resident #51, who also had severe cognitive impairment, urinary retention, and an indwelling urinary catheter, had physician orders for catheter care every shift and Foley catheter care twice daily as needed. During two separate observations, the resident’s catheter drainage tubing was hanging over the bed and the drainage bag was resting on the floor next to the bed. Staff who observed the condition stated that the drainage bag should not be on the floor because it created an infection control concern. The report also cites CDC guidance stating that if leakage occurs, the catheter and collecting system should be replaced using aseptic technique and sterile equipment, and that the collecting bag should be kept below the level of the bladder and not rest on the floor. The Infection Control Nurse stated that staff had been educated on appropriate urinary catheter care and that drainage bags should not be placed on the floor to prevent the spread of infections.
Failure to Use Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards of practice for one resident by not consistently using Enhanced Barrier Precautions during high-contact care. Resident #93 was admitted with diagnoses including urinary retention and essential primary hypertension, had severe cognitive impairment with a BIMS score of 2, and had an indwelling urinary catheter. The resident’s care plan, MDS assessment, and physician’s orders all indicated that Enhanced Barrier Precautions were to be maintained related to the urinary catheter, with PPE required for high-contact care and hand hygiene on entering and exiting the room. The facility’s posted signage outside the resident’s room directed staff to clean their hands before entering and when leaving the room and to wear gloves and a gown for high-contact care activities, including dressing, bathing, transferring, providing hygiene, changing briefs, and device care or use. During observation, a CNA was seen providing ADL care to the resident while wearing gloves but not a gown. The CNA stated he forgot to wear a gown, and acknowledged that a gown was important because the resident had a urinary catheter and to help prevent infection transmission. On another observation, a CNA entered the resident’s room without observed hand hygiene and was later seen providing ADL care while wearing gloves but not a gown. The nurse present stated the CNA should have worn a gown because the resident was on EBP due to the urinary catheter. The CNA stated he should have washed his hands before entering and should have worn a gown, but did not follow the posted sign. The DON stated that staff not wearing the required PPE when caring for the resident on EBP risked transference of pathogens from staff clothing and hands to the resident and to other residents.
Burn Injury from Unchecked Hot Coffee Temperature
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision when serving hot beverages to a resident who required set-up assistance with meals. Facility policy titled “Microwave Safety for Hot Liquids” required that any liquids heated in the microwave have their temperature checked with a thermometer, with an acceptable serving range of 135–155°F. Despite posted reheating instructions and thermometers available near the microwaves, a staff member reheated coffee in a microwave for a resident and did not check the temperature with a thermometer before serving it, contrary to facility policy and expectations. The resident involved had been admitted with diagnoses including lung cancer, congestive heart failure, and chronic respiratory failure, and was on hospice services. An Annual MDS assessment and the resident’s plan of care indicated the resident required set-up assistance for eating. On the day of the incident, the resident was seated in a chair at the bedside when a CNA delivered a supper tray and a cup of coffee that had been reheated in the microwave. The resident refused the supper tray but requested the coffee. While the CNA was removing the supper tray and placing the hot coffee on the tray table, she accidentally bumped the tray table, causing the contents of the cup to spill onto the resident’s upper thighs. Immediately after the spill, nursing staff assessed the resident and initially observed red, blanchable skin on the upper thighs. Subsequent evaluation by a wound physician documented a cluster of second-degree burns on the right thigh and additional first- and second-degree burns on the right and left thighs, requiring daily treatment with silver sulfadiazine cream until healed. Interviews with the CNA, ADON, and DON confirmed that the CNA did not use a thermometer to check the temperature of the reheated coffee before serving it, and that this was not in accordance with the facility’s microwave safety policy and reheating guidelines.
Failure to Assess Abdominal Binder as Physical Restraint
Penalty
Summary
The facility failed to assess the use of an abdominal binder as a physical restraint for a resident with nephrostomy tubes. The resident, who was admitted with acute kidney failure, hydronephrosis, and dementia, had physician's orders to use the abdominal binder to hold drain tubes in place as a safety precaution. However, the facility did not document any assessment of the binder as a restraint until it was brought to their attention by a surveyor. The resident's clinical record lacked evidence of an assessment to determine if the binder could be easily removed by the resident. Observations by the surveyor revealed that the resident was unsteady on their feet and had issues with the nephrostomy bags being loose and falling onto the mattress. Interviews with nursing staff confirmed that the resident frequently removed the restraints and that an assessment should have been completed to evaluate the necessity and appropriateness of the abdominal binder. The Director of Nursing acknowledged that an assessment was not conducted when the binder was applied, which was a requirement according to the facility's policy on physical restraints.
Failure to Update PASARR for Resident with New PTSD Diagnosis
Penalty
Summary
The facility failed to ensure that a Level II Preadmission Screening and Resident Review (PASARR) evaluation was submitted for a resident who demonstrated an increase in behavioral, psychiatric, and mood-related symptoms. The resident, admitted in September 2023 with diagnoses including Bipolar Disorder, Depression, and Anxiety, initially did not meet the criteria for a Level II PASARR evaluation based on the Level I screen. However, subsequent assessments indicated worsening verbal behavior symptoms and new diagnoses, including PTSD, which necessitated a review. Despite these changes, the facility did not update or resubmit the Level I PASARR for an additional review. The resident's medical record showed increased use of medications for anxiety and PTSD, including Prazosin and Buspar, indicating a significant change in the resident's mental health status. Interviews with facility staff confirmed that the Level I screen should have been resubmitted following the new PTSD diagnosis, but it was not, and the facility lacked a PASARR policy to guide such actions.
Failure to Develop Trauma Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive Trauma Informed Care Plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted with diagnoses including Bipolar Disorder, Depression, and Anxiety, exhibited verbal behavior symptoms and had a history of depression and anxiety related to the death of a child. Despite receiving a new diagnosis of PTSD and being prescribed Prazosin for nightmares, the facility did not complete an assessment or develop a care plan addressing the resident's PTSD history and triggers. Interviews with facility staff revealed that the new PTSD diagnosis was not communicated to the social worker, and a trauma assessment was not completed. The social worker acknowledged that a Trauma Informed Care Plan should have been developed but was not. The resident's clinical record showed increased use of anti-anxiety medication, indicating ongoing anxiety issues, yet no trauma-informed interventions were documented in the care plan.
Failure to Safely Administer Furosemide
Penalty
Summary
The facility failed to accurately and safely provide pharmaceutical services for a resident, specifically in the administration of Furosemide, a medication used to treat high blood pressure and heart failure. The resident was admitted with diagnoses of heart failure and hypertension and had a physician's order for Furosemide 10 mg once a day. However, the medication was not dispensed from the pharmacy, and the facility staff resorted to using a higher dose Furosemide 20 mg tablet, which they broke in half to administer the ordered dose. This practice was against the facility's policy, which discourages splitting unscored tablets due to the risk of inaccurate dosing. During the survey, it was observed that the Furosemide medication was not available in the medication cart, and the nurse confirmed that the medication had not been delivered from the pharmacy since it was ordered. The Director of Nursing acknowledged that the medication had not been removed from the facility's automated dispensing system and confirmed that the order for the 10 mg Furosemide never reached the pharmacy. The nurse admitted to borrowing the 20 mg Furosemide from another resident and breaking it to administer to the resident in question, which was against the facility's policy of not borrowing medications between residents.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was transmitted within the required timeframe for a resident. Specifically, a discharge MDS assessment for a resident with unspecified dementia, who was under hospice care and expired at the facility, was not transmitted to the Internet Quality Improvement and Evaluation System (IQIES) within 14 days of its completion. The MDS assessment was completed, but there was no evidence in the clinical record that it was ever transmitted as required. During an interview, the MDS Nurse confirmed that the assessment should have been transmitted within the specified timeframe but acknowledged that it had not been done.
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 721 citations issued within 25 miles in the last 12 months — including the 3 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 Westborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westborough Healthcare | 0.6 mi | ★★★★★ | 6 | 0 |
| Whittier Westborough Transitional Care Unit | 2.1 mi | ★★★★★ | 0 | 0 |
| Beaumont Rehab & Skilled Nursing Ctr - Northboro | 3.2 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Coleman | 3.4 mi | ★★★★★ | 10 | 0 |
| Marlborough Hills Rehabilitation & Health Care Cen | 4.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Beaumont Rehab & Skilled Nursing Ctr - Westboro.
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.