Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Blackstone Valley Health And Rehabilitation during CMS and state inspections, most recent first.
The facility did not request updated Level II PASARR evaluations for two residents who experienced significant changes in psychosocial condition, including suicidal ideation and emergency mental health interventions, despite initial screenings indicating no need for further review. This failure to coordinate assessments and refer for services as needed was confirmed by staff interviews and record review.
A resident with COPD and chronic pain syndrome, who was cognitively intact, was not provided the opportunity to participate in required quarterly care plan meetings. Facility records lacked evidence of care plan meetings, participation, or documentation of refusals, and staff confirmed that the meetings were not held or documented as required.
Two residents were not adequately protected from accident hazards: one with severe cognitive impairment and elopement risk was not included in the facility's Elopement Risk Binder as required, and another cognitively intact resident was found storing smoking materials in their walker, with a missed quarterly Safe Smoking Assessment. Staff interviews and record reviews confirmed lapses in following facility policies for both elopement risk management and safe smoking practices.
A resident with multiple medical conditions and at nutritional risk experienced significant, severe weight loss over several weeks without receiving a required nutritional assessment or timely intervention from the dietician. Despite facility policy requiring prompt assessment and action for notable weight changes, staff failed to communicate the issue or implement appropriate care, resulting in unaddressed nutritional decline.
Two residents receiving oxygen therapy were found to have oxygen concentrator filters covered in thick dust, despite documentation indicating weekly cleaning. Both residents, one with severe cognitive impairment and another with chronic heart failure, were observed using equipment that had not been properly maintained according to physician orders, manufacturer guidelines, and facility policy. Nursing staff confirmed the filters should have been cleaned but acknowledged this was not done.
A resident with dementia and CKD did not have timely responses or implementation of repeated Consultant Pharmacist recommendations, including obtaining a Vitamin D level and discontinuing Loratadine. Despite provider agreement, actions were delayed for months, and required documentation of MRRs was missing from the clinical record.
A resident with dementia and chronic kidney disease continued to receive Loratadine for over three months after the provider had agreed to discontinue it, despite repeated recommendations from the Consultant Pharmacist and established procedures for implementing such orders. The DON confirmed that the medication was not discontinued as directed, and could not provide a reason for the delay.
Surveyors found that two residents received incorrect medication dosages or forms, resulting in a medication pass error rate of 6.9%, which is above the acceptable 5% threshold. Errors included administering a tablet instead of an oral solution via G-Tube and giving double the prescribed dose of Fish Oil. Nursing staff acknowledged the errors during interviews.
Surveyors found that multiple food items in the main kitchen walk-in refrigerator, including ham salad, cubed chicken, and various vegetables, were stored without required labels or dates. The Food Service Director confirmed that these items should have been labeled and dated per facility policy and FDA Food Code, but were not, resulting in a failure to follow proper food safety and sanitation standards.
A resident with bilateral knee osteoarthritis did not receive a timely PT evaluation as ordered by a physician, despite ongoing pain and a referral for therapy. The resident was only approached once for PT, which was not completed due to illness, and was instead evaluated by OT without assessment of knee pain or stiffness. There was no evidence the resident was re-approached for PT after recovery, and staff interviews confirmed the PT evaluation was not completed as ordered.
A nurse failed to clean and disinfect a blood glucose monitor after using it on a resident and before returning it to the medication cart with other clean equipment. This action was not in accordance with facility policy, which requires all shared medical equipment to be disinfected between uses to prevent the spread of infection.
Failure to Update PASARR Assessments After Significant Psychosocial Changes
Penalty
Summary
The facility failed to ensure that Level II Preadmission Screening and Resident Review (PASARR) evaluations were requested for two residents following significant changes in their psychosocial conditions that required emergency mental health interventions. For one resident with diagnoses including Anxiety Disorder, Depression, and PTSD, the initial Level I PASARR screen was negative, and no Level II evaluation was deemed necessary at admission. However, the resident later exhibited suicidal ideation on two separate occasions, resulting in transfers to the emergency department for further evaluation. Despite these significant changes, the facility did not update or resubmit the Level I PASARR for an additional review and Level II evaluation. Another resident, admitted with Major Depressive Disorder, Anxiety, and Depression, had a Level I PASARR indicating a history of mood and anxiety disorders, and a Level II determination that no further PASARR involvement was required. This resident subsequently made multiple statements about suicidal ideation, leading to hospital admissions for evaluation and observation. The facility did not report these changes in status to the PASARR office, as confirmed by the social worker. The failure to coordinate updated PASARR assessments following these acute psychosocial events constituted the deficiency.
Failure to Conduct and Document Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was provided the right to participate in the care plan process, as required by facility policy. Specifically, the facility did not conduct quarterly care plan meetings for a resident with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and chronic pain syndrome, who was cognitively intact at the time of the deficiency. The facility's policy requires that residents and their families be invited to participate in care planning conferences, with advance notice, documentation of attendance, and follow-up if the resident or representative cannot attend. Record review showed no evidence that the required care plan meetings were held or that the resident or their representative participated in the process for the scheduled quarters. There was also no documentation of any refusals to participate or of any contact made to review the care plan information with the resident or representative. Interviews with facility staff confirmed that the meetings were not held as scheduled and that there was no documentation to support that the care planning process was followed for the resident during the specified periods.
Failure to Prevent Accident Hazards Related to Elopement and Smoking Materials
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, resulting in deficiencies related to elopement risk management and safe smoking practices. One resident with severe cognitive impairment, dementia, and anxiety disorder was identified as an elopement risk upon admission, with behaviors such as wandering, expressing a desire to go home, and staying near exits. Although the facility's policy required that residents at risk for elopement be included in an Elopement Risk Binder with their photograph and information, this resident was not added to the binder at the front desk or nurses' stations. Staff interviews confirmed that the resident's risk evaluation was not properly completed to indicate inclusion in the binder, and the required documentation and photograph were missing. Another resident, who was cognitively intact and a smoker, was found to have smoking materials, including a cigarette box, lighter, and used cigarettes, stored in the compartment of a rolling walker in their room. Facility policy required that all smoking materials be kept at the nurses' station and disposed of properly after use to prevent fire hazards. Staff confirmed that the resident should not have had smoking materials in their possession and that storing them in the walker was a fire hazard. Additionally, the facility failed to complete a required quarterly Safe Smoking Assessment for this resident, as indicated by a gap in the assessment schedule between two documented assessments. These deficiencies were identified through record reviews, staff and resident interviews, and direct observation. The facility's failure to follow its own policies regarding elopement risk management and safe smoking practices resulted in lapses in supervision and the presence of accident hazards for the affected residents.
Failure to Complete Nutritional Assessment and Intervene for Significant Weight Loss
Penalty
Summary
Facility staff failed to provide appropriate nutritional care and services for a resident identified as being at risk for altered nutrition status. Upon admission, the resident, who had diagnoses including Multiple Sclerosis, dysphagia, and Major Depressive Disorder, did not receive a required nutritional assessment by the dietician. The facility's policy mandates that a nutritional assessment be completed within a day or two of admission and that significant weight changes be documented and addressed. Despite the resident experiencing a significant and severe weight loss over several weeks, there was no evidence in the clinical record that a nutritional assessment was completed or that the dietician made any recommendations or interventions. The resident's weight records showed a 7.5% to 9.8% weight loss over a short period, which met the facility's criteria for severe weight loss. Although the care plan identified the resident as being at nutritional risk and included interventions such as monitoring meal intake and obtaining lab work, there was no documentation of follow-up or action taken in response to the weight loss. Interviews with facility staff revealed that the dietician was unaware of the resident's weight loss and had not reviewed the weight records, and the unit manager was not informed of the issue. The lack of communication and failure to follow established protocols led to the deficiency in providing adequate nutrition and monitoring for the resident.
Failure to Maintain Clean Oxygen Concentrator Filters for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for two residents who required oxygen therapy. For one resident with severe cognitive impairment and diagnoses including encephalopathy and obstructive sleep apnea, the oxygen concentrator's air intake gross particle filter was repeatedly observed with a thick coating of dust on multiple occasions. Despite physician orders and documentation indicating weekly cleaning of the filter, the filter remained visibly soiled, and the resident reported ongoing difficulty breathing. Additionally, a bottle of sterile water intended for use with the concentrator was found on the floor rather than in its designated storage area. For another resident with chronic diastolic heart failure and moderate cognitive impairment, the oxygen concentrator's removable filter was also observed to be covered in a thick layer of gray dust over several days. This resident used oxygen therapy primarily at night and expressed concern about the cleanliness of the equipment, stating reluctance to breathe through a visibly dirty filter. Documentation indicated that the filter was supposed to be cleaned weekly, but observations contradicted these records, showing a lack of proper maintenance. Interviews with nursing staff confirmed that the filters should have been cleaned weekly in accordance with both manufacturer guidelines and facility policy, but acknowledged that this had not occurred. The failure to maintain clean and sanitary oxygen concentrator filters as required by physician orders, manufacturer instructions, and facility policy resulted in the equipment being left in a condition that could compromise its function and the quality of care provided to the residents.
Failure to Timely Respond to and Implement Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely response and implementation of Medication Regimen Review (MRR) recommendations for a resident with dementia and chronic kidney disease. The Consultant Pharmacist made repeated recommendations to obtain a Vitamin D level on three separate occasions, but there was no documented evidence that the initial recommendation was reviewed or responded to by the provider. Although the provider eventually agreed to the recommendation, the Vitamin D level was not obtained until after multiple MRRs and provider consents. Additionally, the facility failed to maintain documentation of the MRRs in the resident's clinical record as required by policy. Repeated recommendations were also made by the Consultant Pharmacist to discontinue Loratadine, an antihistamine medication, over several months. While the provider agreed to discontinue the medication, there was no evidence that the order was implemented until several months later. The Director of Nursing was unable to provide documentation for several MRRs and could not explain the delay in discontinuing the medication after provider agreement. The process for handling MRRs involved emailing recommendations to the Unit Manager and placing them in the Provider's Communication Book, but this process did not ensure timely review or implementation of the pharmacist's recommendations.
Failure to Discontinue Unnecessary Medication After Provider Approval
Penalty
Summary
A resident with diagnoses including dementia and chronic kidney disease was admitted to the facility and was prescribed Loratadine, an antihistamine medication. The Consultant Pharmacist made repeated recommendations to discontinue Loratadine, which were communicated to both the provider and nursing staff over several months. On 10/8/24, the provider agreed with the recommendation to discontinue the medication, and this agreement was documented in the resident's clinical record. Despite this, the resident continued to receive scheduled doses of Loratadine for over three months, as indicated by the Medication Administration Records, until the medication was finally discontinued on 2/4/25. The Director of Nursing (DON) confirmed during interviews that the process for handling Consultant Pharmacist recommendations involved emailing the Unit Manager, printing the recommendations, and placing them in the Provider's Communication Book. The DON stated that nursing staff were expected to check the communication book every shift and implement provider-approved orders immediately. However, the DON was unable to explain why the Loratadine was not discontinued as ordered, acknowledging that the medication continued to be administered unnecessarily after the provider had agreed to stop it.
Medication Pass Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication pass error rate of less than 5%, resulting in a 6.9% error rate during the survey. This deficiency was identified through observation, interview, and record review, where two residents out of five applicable residents experienced medication administration errors out of 29 opportunities. The facility's policies required adherence to the Five Rights of Medication Administration and safe medication practices, but these were not followed in the observed incidents. One resident with a history of cerebral infarction, hemiplegia, dysphagia, and failure to thrive was ordered to receive Ferrous Sulfate Oral Solution via G-Tube, but was instead administered a crushed Ferrous Sulfate tablet. The nurse acknowledged the error during an interview. Another resident with diagnoses including normal pressure hydrocephalus, Parkinson's Disease, heart disease, and dementia was ordered to receive two 500 mg Fish Oil capsules (total 1000 mg) but was given two 1000 mg capsules (total 2000 mg). The nurse also confirmed the error during an interview. These actions directly led to the facility exceeding the acceptable medication error rate.
Failure to Label and Date Food Items in Main Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards of food safety and sanitation in the main kitchen. Specifically, multiple food items stored in the walk-in refrigerator—including ham salad, cubed chicken, halved tomatoes, sliced cucumbers, and diced onions—were found to be unlabeled and undated. These observations were made during a walkthrough with the Food Service Director (FSD), who confirmed that all food items should have been labeled and dated according to facility policy and FDA Food Code requirements. The facility's policy and the FDA Food Code both require that prepared and ready-to-eat foods stored for more than 24 hours be clearly marked with the date of preparation or opening, and that such foods be discarded after a specified period. The FSD acknowledged during the interview that the undated food items should have been discarded, indicating a lapse in following established food storage protocols. No information about specific residents or their conditions was provided in the report.
Failure to Provide Timely Physical Therapy Evaluation for Knee Osteoarthritis
Penalty
Summary
A deficiency occurred when the facility failed to provide specialized rehabilitative services as required for a resident with bilateral primary osteoarthritis of the knees. The resident was referred by an orthopedic physician for a physical therapy (PT) evaluation and treatment to address knee pain and stiffness, with a specific order for PT to be conducted 2-3 times per week for 6-8 weeks. However, there was no evidence that a PT evaluation was completed following the physician's referral. The resident continued to experience pain that interfered with sleep and daily activities, as documented in the Minimum Data Set (MDS) assessment. Four months after the initial referral, a new request for a rehabilitation screen was made due to increased knee pain, and a subsequent physician's order again called for a PT evaluation. Despite these orders, the resident was only approached once for a PT evaluation, which was not completed due to the resident's temporary illness. Occupational therapy (OT) was conducted instead, but the OT evaluation did not assess knee pain or stiffness as specified in the PT order. There was no documentation that the resident was re-approached for PT after recovering from the illness. Interviews with rehabilitation staff confirmed that the PT evaluation was not completed as ordered and that the staff was unaware of the initial referral and order for PT services.
Failure to Disinfect Shared Blood Glucose Monitor Between Resident Uses
Penalty
Summary
Facility staff failed to adhere to infection prevention and control standards regarding the use of multi-resident medical equipment. During a medication administration observation, a nurse used a blood glucose monitor (BGM) to obtain a blood glucose level for a resident and then placed the BGM back into the medication cart with other clean equipment without cleaning or disinfecting it. The nurse acknowledged forgetting to clean the BGM after use, and both the unit manager and infection preventionist confirmed that facility policy requires all shared equipment, including BGMs, to be cleaned and disinfected between each resident use. The facility's policy on disinfecting shared resident equipment specifies that all such equipment must be cleaned and disinfected routinely, using methods appropriate for the equipment and type of contamination. Despite this policy, the observed nurse did not follow the required procedure after using the BGM, resulting in a failure to prevent potential transmission of communicable diseases and infections. This deficiency was identified for one resident out of a sample of 25 during the survey.
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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 Whitinsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare At Northbridge | 2.6 mi | ★★★★★ | 6 | 0 |
| Lydia Taft House | 4.7 mi | ★★★★★ | 4 | 0 |
| Countryside Health Care Of Milford | 6.3 mi | ★★★★★ | 5 | 0 |
| Blaire House Of Milford | 8 mi | ★★★★★ | 2 | 0 |
| Care One At Millbury | 8.4 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.