Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Briarwood Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Failure to document staff COVID-19 vaccine education and vaccination status. The facility's policy stated employee vaccination status would be assessed before or upon duty assignment and that declined vaccines would be documented, but the Infection Preventionist said the facility did not keep records of SARS or COVID-19 vaccine education or whether employees received or declined the vaccine. A Nurse Consultant confirmed there was no documentation for the sampled staff.
A resident with severe cognitive impairment and a midline IV for IV antibiotics had deficient IV care when nursing staff did not document the external catheter length as ordered with dressing changes and as needed. The record also lacked an order and documentation for an IV dressing change outside the ordered 7-day schedule, and the DON confirmed there was no order for that dressing change and no nursing documentation explaining it.
A resident with ESRD and dialysis dependence had a removed left chest dialysis catheter still documented in the TAR, and nurses signed off monitoring orders after the catheter was no longer present. Another resident with diabetes had MAR and order entries for both a Dexcom G7 and a Libre 2 Plus CGM sensor, even though staff and the resident confirmed only the Libre 2 Plus sensor was used. The DON stated nurses should only sign off orders when they are actually completed.
A resident was not documented as being offered the pneumococcal or COVID-19 vaccines on admission, despite facility policy requiring that residents be assessed and offered these vaccines with education and refusal documentation. The resident later stated vaccines were not offered until weeks after admission and signed consent for pneumococcal and RSV vaccines while declining the COVID-19 vaccine; the IP and a nurse consultant believed the vaccines had been offered earlier, but no record supported that.
A resident with a history of PE and DVT was not continued on Eliquis after the stop date, despite the HCA's request and physician's indication to continue. The resident did not receive the medication, leading to hospitalization for new bilateral pulmonary emboli. This highlights a lapse in medication management and communication within the facility.
The facility failed to follow professional standards for two residents. A resident's PICC line was not properly monitored due to an obscuring dressing, contrary to physician orders. Another resident received medications in a crushed form despite instructions to administer them whole. Staff interviews revealed a lack of awareness and misunderstanding regarding these practices.
A facility failed to ensure proper communication and coordination of dialysis care for a resident with ESRD. Despite policies requiring ongoing communication between the LTC and dialysis center, documentation was inconsistent, with incomplete or missing communication forms and post-dialysis weights. Staff interviews revealed that the dialysis center often failed to return necessary documentation, and the current communication system was inadequate, leading to a deficiency in providing safe dialysis care.
A nurse in an LTC facility made four medication errors out of 27 opportunities, resulting in a 14.81% error rate. The errors involved crushing medications that should not be altered, such as Ferrous Sulfate, Alfuzosin HCL ER, and Metoprolol Succinate ER, and administering Acidophilus with Pectin instead of the prescribed Acidophilus. Misunderstandings about medication administration were evident among staff, contributing to the errors.
The facility did not follow its COVID-19 testing policy during an outbreak on the [NAME] Unit. Testing was required every 48 hours, but gaps were noted on several dates. The IP confirmed no additional guidance was received, and the ADON acknowledged the testing procedure was not followed as per policy.
A facility failed to ensure a resident's advanced directives were reviewed and followed. The resident, with severe cognitive impairment, was admitted with a guardianship that did not authorize decisions on advanced directives. Despite a MOLST form indicating DNR status, it was voided due to lack of authorization, and the resident was listed as full code. The facility did not pursue changing the code status as per the family's wishes, leading to a deficiency.
Failure to Document Staff COVID-19 Vaccine Education and Status
Penalty
Summary
The facility failed to document whether it educated staff about severe acute respiratory syndrome (SARS) or the COVID-19 vaccine, and failed to document whether staff received or declined the COVID-19 vaccine. Review of the facility policies for COVID-19 Vaccine and Employee Infection and Vaccination Status, last reviewed in 2026, stated that prior to or upon an employee's duty assignment, the facility would assess the employee's vaccination status against infectious conditions and that employees would be current with mandated vaccinations prior to performing resident care. The policy also stated that vaccinations declined by an employee would be documented on the applicable form. During interview, the Infection Preventionist stated the facility did not think it documented employees' education or vaccination status. When asked for documentation for one sampled employee and then four additional sampled staff members, the Infection Preventionist said the facility did not keep employee records of SARS or COVID-19 vaccine education, or records showing whether employees had received the SARS or COVID-19 vaccine. Nurse Consultant #1 also stated the facility had not documented whether the five sampled staff had declined or been administered the COVID-19 vaccine.
Failure to Follow IV Catheter and Dressing Change Orders
Penalty
Summary
Facility staff failed to provide IV care in accordance with the physician’s orders for Resident #129, who was readmitted in June 2026 with diagnoses including osteomyelitis in the vertebra, a sacral pressure ulcer, sepsis, chronic kidney disease, and adult failure to thrive. The resident’s MDS dated 5/28/26 indicated severe cognitive impairment, and during an observation on 6/15/26 the resident was in bed with eyes closed and could not be interviewed. An IV pole was present next to the bed, and the hospital discharge summary showed a midline double lumen catheter had been placed on 6/2/26. The physician’s order dated 6/3/26 directed nursing staff to document the baseline external length of the IV catheter and to check the external length with each dressing change and as needed. Review of the MAR, TAR, and progress notes from 6/3/26 through 6/16/26 failed to show documentation that the external length was obtained on 6/4/26 or 6/11/26. The MAR showed the order as blank and unsigned on 6/4/26 and later marked NA and initialed by Nurse #1 on 6/11/26, with NA identified in the chart codes as meaning no interventions required. The care plan also failed to indicate a person-centered care plan with a measurable goal and specific interventions for IV therapy. The record also failed to show an order and documentation supporting an IV dressing change dated 6/14/26, which was outside the established order to change the transparent dressing every 7 days. During observation on 6/17/26, Nurse #1 and the surveyor saw the dressing on the resident’s right upper arm and Nurse #1 stated the handwritten dressing date read 6/14/26. The MAR showed dressing-change orders beginning on admission and then every 7 days, with documentation of administration on 6/5/26 and 6/11/26, but the clinical record did not include an order for the 6/14/26 dressing change, the reason for the change, or the resident’s response to the procedure. The DON stated there was no order for the 6/14/26 dressing change and that documentation should have been entered by the nurse.
Inaccurate documentation of dialysis access and glucose sensor use
Penalty
Summary
The facility failed to maintain accurate medical records for two residents by documenting treatments and devices that did not match their actual clinical status. Resident #6, who was admitted with end stage renal disease and dependence on renal dialysis, was cognitively intact and reported receiving dialysis through a right arm access site. During observations, the resident stated that a left chest port had been removed about one month earlier, and no central port catheter was present on the chest when observed. Despite the catheter removal, the resident’s record still contained a TAR order for monitoring a left chest wall central catheter every shift, and nursing staff signed off that order on multiple shifts after the catheter had already been removed. The clinical record also included an after-visit summary documenting removal of the left tunneled dialysis catheter. Staff interviews reflected confusion about the resident’s dialysis access, with one nurse believing the resident still had a chest port and the unit manager stating the resident had an arm fistula that was not yet in use. The DON stated nurses should only sign off orders if they are completed and acknowledged the order should not have been signed after the catheter was removed. A similar documentation error occurred for Resident #12, who had diagnoses including type 2 diabetes, chronic kidney disease, dementia, and adult failure to thrive, and was cognitively intact on MDS assessment. The resident stated the sensor was not working and staff were waiting for a new one, and later showed a Libre 2 Plus sensor on the upper arm. The record, however, included physician orders and MAR entries for both a Dexcom G7 sensor and a Libre 2 Plus sensor, and nursing staff signed off the Dexcom sensor as administered even though staff interviews confirmed the resident had only used a Libre 2 Plus sensor and had never had a Dexcom sensor at the facility.
Failure to Document Offering Pneumococcal and COVID-19 Vaccines
Penalty
Summary
The facility failed to ensure that one resident was offered the pneumococcal and COVID-19 vaccines. Facility policies stated that all residents would be assessed for eligibility and offered the pneumococcal vaccine series and the COVID-19 vaccine upon or prior to admission, with education documented in the medical record and refusals recorded if applicable. Resident #97 was admitted in April 2026, but review of the medical record on 6/15/26 showed no documentation that staff offered either vaccine or that the resident accepted or refused them. During an interview on 6/17/26, the resident stated that staff had not offered any vaccines on admission and that the first vaccine discussion occurred the day before the interview, approximately ten weeks after admission. The resident said he/she signed consents for the pneumococcal and RSV vaccines and declined the COVID-19 vaccine. The Infection Preventionist and Nurse Consultant #1 stated they believed the pneumococcal and COVID-19 vaccines had been offered on admission, but there was no record of this or of any refusal. A later record review showed signed informed consent forms for the RSV and pneumococcal vaccines and a signed decline for the COVID-19 vaccine.
Failure to Continue Anticoagulation Therapy Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that nursing provided care and services that met professional standards of practice related to medication review and physician follow-up for a resident with a history of pulmonary embolism (PE) and deep vein thrombosis (DVT). The resident was being treated with Eliquis, an anticoagulant, which had a physician's order with a stop date. Despite the resident's Health Care Agent (HCA) requesting that the resident remain on Eliquis, and the physician's progress note indicating to continue the medication, no new order was obtained by nursing, leading to the discontinuation of Eliquis. The resident, who had been admitted to the facility with diagnoses including a pulmonary embolism and a lower left extremity DVT, was initially prescribed Eliquis with a specific dosage and duration. However, after the stop date, the resident did not receive Eliquis, despite the HCA's request and the physician's indication to continue the medication. This oversight resulted in the resident not receiving the necessary anticoagulation therapy from the stop date until the resident was transferred to the hospital. On the day of the transfer, the resident was found to have acute shortness of breath and was diagnosed with new bilateral pulmonary emboli at the hospital. The facility's failure to obtain a new order for Eliquis and ensure its administration led to the resident's hospitalization for recurrent blood clots, highlighting a significant lapse in medication management and communication within the facility.
Failure to Follow Professional Standards in Medication Administration and PICC Line Monitoring
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, leading to deficiencies in care. For Resident #261, the facility did not properly monitor the resident's right upper extremity Peripherally Inserted Central Catheter (PICC) insertion site for signs of infection as per the physician's order. The PICC line dressing was observed to have a large white gauze under the clear dressing, completely obscuring the insertion site, which was against the facility's policy that required a transparent dressing for monitoring. Despite this, nurses had been signing off on the Medication Administration Record (MAR) that they were monitoring the site, although the site was not visible due to the gauze. For Resident #211, the facility failed to administer medications according to the physician's order and medication guidelines. The resident was given medications that should not be crushed, such as Ferrous Sulfate, Alfuzosin HCL ER, and Metoprolol Succinate ER, in a crushed form mixed with applesauce. This was contrary to the pharmacy label and medication administration guidelines, which clearly indicated that these medications should be swallowed whole. Nurse #1 admitted to crushing these medications due to the resident's difficulty swallowing, despite the clear instructions not to do so. Interviews with the Unit Manager and Assistant Director of Nursing revealed a lack of awareness and misunderstanding regarding the proper administration of these medications and the monitoring of the PICC line. The Unit Manager and ADON acknowledged that the medications should not have been crushed and that the PICC line dressing should have been transparent to allow for proper monitoring. These deficiencies highlight a failure in following professional standards and physician orders, impacting the quality of care provided to the residents.
Inadequate Communication in Dialysis Care Coordination
Penalty
Summary
The facility failed to ensure proper communication and coordination of dialysis care for a resident with End-Stage Renal Disease (ESRD) who was dependent on renal dialysis. The facility's policy required ongoing communication between the nursing facility and the dialysis center, including the exchange of relevant information such as physician orders, laboratory results, and post-treatment reports. However, the facility did not maintain consistent communication, as evidenced by incomplete or missing documentation in the Dialysis Communication Book and a lack of documented communication in the Nursing Progress Notes. Resident #102, who was cognitively intact and required interpreter services, received dialysis three times a week. Despite this, the facility's records showed that post-dialysis weights were only documented 59% of the time, and there were numerous instances where the communication forms were either incomplete or missing entirely. Interviews with staff revealed that the dialysis center often failed to return the communication forms, and weights were sometimes provided on sticky notes rather than documented properly. Staff members acknowledged the inconsistency in communication and the inadequacy of the current system. The Assistant Director of Nurses and other staff members admitted that the communication process was flawed, with the dialysis center not consistently returning the necessary documentation. The corporate communication form was described as confusing and too lengthy, contributing to the breakdown in communication. Despite the facility's policy and coordination agreement with the dialysis center, there was a significant lack of documented evidence of care coordination, leading to the deficiency in providing safe and appropriate dialysis care for the resident.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by one nurse making four errors in 27 opportunities, resulting in a 14.81% error rate. These errors affected one resident, who was administered medications incorrectly. The nurse prepared nine morning medications for the resident, including both oral and topical forms. However, the nurse crushed and mixed several medications that should not have been altered, such as Ferrous Sulfate, Alfuzosin HCL ER, and Metoprolol Succinate ER, which are extended-release and should be swallowed whole. Additionally, the nurse administered Acidophilus with Pectin instead of the prescribed Acidophilus capsule. Interviews with the nurse and other staff revealed misunderstandings and incorrect assumptions about medication administration. The nurse believed that Ferrous Sulfate could be crushed and that Acidophilus with Pectin was equivalent to the prescribed Acidophilus. The Unit Manager and Assistant Director of Nursing also shared similar misconceptions, indicating a lack of awareness regarding the proper administration of these medications. The errors were compounded by the resident's difficulty swallowing, which led the nurse to crush medications that should not have been altered, without seeking alternative solutions or orders.
Failure to Follow COVID-19 Testing Policy During Outbreak
Penalty
Summary
The facility failed to adhere to its COVID-19 testing policy during an outbreak on the [NAME] Unit. The policy required testing of exposed residents and staff every 48 hours until the facility went 7 days without a new case. However, the facility did not conduct testing at the required intervals. On 6/24/24, two residents tested positive, marking the start of the outbreak. Testing was not conducted every 48 hours as required, with gaps noted on 6/26/24, 7/3/24, and 7/7/24. The Infection Preventionist (IP) confirmed that no additional guidance was received from a DPH epidemiologist, and the facility was supposed to follow its policy. The testing logs revealed inconsistencies in testing both residents and staff. While all residents were tested on certain dates, there were days when testing was not conducted as per the policy. Similarly, staff testing was not conducted on 6/26/24, 48 hours after the initial outbreak testing began. The Assistant Director of Nursing (ADON) acknowledged that the COVID-19 testing procedure was not conducted in accordance with the facility's policy, and the IP could not provide documentation to demonstrate compliance with the testing schedule.
Failure to Follow Advanced Directives for Resident
Penalty
Summary
The facility failed to ensure that the advanced directives for a resident with severe cognitive impairment were reviewed and followed. The resident, who had a history of stroke and dementia, was admitted with a guardianship arrangement that did not authorize the guardians to make decisions regarding advanced directives. Despite having a MOLST form indicating a Do Not Resuscitate (DNR) status, the form was marked as void due to lack of authorization, and the resident was listed as a full code in the medical records. Interviews revealed that the family believed the resident was a DNR and had discussed this with the facility, but there was no documentation to support that the facility pursued changing the code status as per the family's wishes. The social worker involved was not the regular social worker for the resident and was unaware of any conflict among the co-guardians regarding the code status. The facility's records did not show any legal pursuits to change the resident's code status, and the family's attorney confirmed they were not working on expanding the guardianship to include advanced directives. The facility's failure to act on the family's wishes and the lack of documentation regarding the pursuit of changing the code status led to the deficiency.
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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 Needham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Skilled Nursing Facility At North Hill (the) | 1.3 mi | ★★★★★ | 0 | 0 |
| Newbridge On The Charles Skilled Nursing Facility | 2 mi | ★★★★★ | 1 | 0 |
| Elizabeth Seton | 2.7 mi | ★★★★★ | 0 | 0 |
| Stone Rehabilitation And Senior Living | 2.7 mi | ★★★★★ | 5 | 0 |
| Care Village At Parkway | 3.3 mi | ★★★★★ | 14 | 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 August 2026) and official state health department websites.