Above 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 Brockton Post Acute Care during CMS and state inspections, most recent first.
A resident admitted for hospice respite care with multiple chronic conditions received medications that were not accurately reconciled upon admission. Nursing staff used an outdated medication list, resulting in the administration of risperidone at the wrong time and a discontinued scopolamine patch. Facility staff interviews revealed confusion over which medication list was current and a lack of adherence to medication reconciliation policy.
A facility failed to involve a resident and their family in the development and implementation of the resident's care plan. Despite the resident being cognitively intact, no care plan meeting was held following the completion of the resident's Quarterly MDS Assessment. Staff interviews revealed a lack of awareness and communication regarding care plan meeting schedules, exacerbated by the resignation of the Former Director of Social Services, leading to missed meetings.
A resident was moved to a new room without receiving the required written notice or explanation, despite expressing a desire to stay in the original room. The facility's policy mandates informing residents and their representatives about room changes, but this was not followed. Interviews revealed that the resident's family was not informed, and there was no documentation of the resident's agreement or awareness of the change.
A resident admitted with pressure injuries had incomplete medical records, as the facility failed to document these injuries in admission and weekly skin assessments. Despite the hospital discharge summary indicating multiple pressure injuries, the facility's records did not reflect this, and staff interviews revealed a lack of awareness and recall of the resident's condition. The facility's policy requires thorough documentation of all skin assessments, which was not followed in this case.
Failure to Accurately Reconcile and Administer Medications Upon Admission
Penalty
Summary
Nursing staff failed to accurately reconcile and administer medications for a resident admitted for a five-day hospice respite stay with diagnoses including COPD, CHF, and dementia. Upon admission, the facility received two different medication lists from hospice, one of which was outdated and included a discontinued medication. The Unit Manager used the original, outdated list to reconcile medications with the physician, resulting in the transcription of incorrect medication orders. Specifically, risperidone was ordered and administered in the morning instead of the evening as per the current hospice medication list, and a scopolamine transdermal patch was administered despite its discontinuation prior to admission. Interviews with facility staff revealed a lack of clarity regarding which medication list was used for reconciliation and a failure to verify the most current orders. The Director of Nursing was unaware of the errors and the existence of two medication lists in the resident's record. The facility's policy required accurate reconciliation of all medications, including dose, route, and frequency, with the physician upon admission, but this was not followed, resulting in the administration of medications at incorrect times and the use of a discontinued medication.
Failure to Involve Resident and Family in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident and their family member or legal representative participated in the development and implementation of the resident's person-centered care plan. This deficiency was identified for a resident who was admitted with multiple diagnoses, including necrotizing cellulitis, diabetes mellitus, peripheral vascular disease, and fibromyalgia. Despite being cognitively intact, as indicated by a BIMS score of 13, the resident and their family member were not involved in a care plan meeting following the completion of the resident's Quarterly MDS Assessment. The facility's policy requires that residents and their families be involved in care plan meetings, which should occur at 90-day intervals, but this did not happen for the resident in question. Interviews with facility staff revealed a lack of awareness and communication regarding the scheduling and execution of care plan meetings. The Unit Manager was unaware that the resident had not had a care plan meeting, and the Social Worker indicated that the care plan meeting schedule was disrupted due to the resignation of the Former Director of Social Services. Additionally, the Assistant Director of Nurses was not informed that care plan meetings were not being completed in a timely manner. This lack of coordination and oversight led to the failure to conduct a care plan meeting for the resident, as required by the facility's policy.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to honor a resident's right to receive written notice and an explanation before a room change, as required by their policy. The resident, who was alert, oriented, and capable of making decisions, was moved to a new room without being informed or given a choice, despite expressing a desire to remain in the original room. The facility's policy mandates that residents or their representatives be informed both verbally and in writing about room changes, including the reasons for such changes. However, in this case, the resident was not provided with any written notice or explanation, nor was the resident introduced to the new roommate or shown the new room prior to the move. Interviews with the resident, a family member, and facility staff revealed that the facility did not follow its own procedures for room changes. The resident's family member, who was actively involved in the resident's care, was not informed of the room change, and the resident did not receive a Notice of Room Change 48 hours prior to the move, as required. Additionally, there was no documentation in the resident's medical record to indicate that the resident agreed to the room change or was aware of the reasons for it. The Director of Nurses acknowledged that the facility's expectations were not met in this instance, as the resident and their responsible party were not informed of the reason for the room change, nor was the resident given the opportunity to view the new room or meet the potential new roommate before the move.
Failure to Document Pressure Injuries on Admission
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with multiple pressure injuries. The facility's policy requires documentation of all services provided, progress toward care plan goals, and any changes in the resident's condition. However, upon review, it was found that the resident's admission skin assessments and weekly skin assessments did not document the presence of pressure injuries, despite the hospital discharge summary indicating their existence. The resident was admitted with diagnoses including necrotizing cellulitis, diabetes mellitus, peripheral vascular disease, and fibromyalgia. The hospital discharge summary noted the presence of a Stage 3 pressure injury to the coccyx, an unstageable pressure injury to the right ischium, and a Stage 2 pressure injury to the left ischium. Despite these documented conditions, the facility's records, including admission and weekly skin assessments, failed to reflect these pressure injuries, and the treatment administration records lacked documentation supporting the presence of these injuries. Interviews with facility staff revealed a lack of awareness and recall regarding the resident's pressure injuries upon admission. The admitting nurse and other staff members could not recall the resident's skin conditions accurately, and the Director of Nurses was unaware of the pressure injuries. The facility's policy mandates a thorough head-to-toe assessment upon admission, weekly, and as needed, with all findings documented, but this was not adhered to in the case of this resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alliance Health At West Acres | 0.7 mi | ★★★★★ | 6 | 0 |
| The Guardian Center | 1.3 mi | ★★★★★ | 2 | 0 |
| The Center At Blue Hills | 2.1 mi | ★★★★★ | 4 | 0 |
| St Joseph Manor Health Care Inc | 2.5 mi | ★★★★★ | 4 | 0 |
| Champion Rehabilitation And Nursing Center | 2.7 mi | ★★★★★ | 8 | 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.