Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Care One At Brookline during CMS and state inspections, most recent first.
Failure to Maintain Resident Dignity and Privacy During Meals and Personal Care: Two residents who needed help with meals were observed with trays left out of reach and staff standing over them while feeding, rather than providing a dignified dining experience. Another resident was repeatedly seen with the chest visible from the hallway, and a fourth resident was observed with a brief visible from the hallway on multiple occasions. Staff stated that residents should not be exposed or visible from the hallway and that meal assistance should be provided at eye level.
Respiratory care was not provided as ordered for three residents. One resident with COPD and acute respiratory failure was observed receiving O2 at a higher flow rate than ordered, with unlabeled and improperly stored respiratory equipment, while two other residents with COPD, chronic respiratory failure, and trach/suction needs had nebulizer, suction, and Yankauer supplies left out in the open, unlabeled, and not stored in bags as required by the physician orders and facility policy.
Unlocked Medication Carts: Medication carts were left unlocked on the first and second floor units, with no nurse in sight on one unit and staff and residents nearby on the other. An RN said she left the cart unlocked when she went to pick up takeout food and drinks, and Corporate Nurse stated carts are to be locked at all times.
The facility failed to provide a homelike dining environment on the second-floor unit when residents were observed eating breakfast and lunch in the dining room from meal trays. Surveyors observed multiple residents, including one being assisted by staff, eating meals on trays during repeated meal observations. The facility policy did not state that meals are served in a homelike manner, and the DON stated that meals are not supposed to be served off trays.
Failure to implement an ordered knee immobilizer care plan was identified for a resident with a right tibial fracture, brain cancer, malnutrition, and severe cognitive impairment. Surveyors observed the immobilizer left across the room while the resident remained in bed, and the record did not show refusal documentation or MD notification. An LPN stated ordered care must be followed and refusals documented, and the DON stated staff must follow physician orders and the care plan at all times.
Failure to Address Dialysis Medication Recommendation: A resident with ESRD and severe cognitive impairment returned from dialysis with a recommendation for sevemar carbonate to be given with meals for phosphate control, but the medical record did not show that the physician was contacted to approve or deny the recommendation. The Unit Mgr and DONs stated the dialysis communication book should be reviewed after dialysis and the physician contacted promptly, within 24 hours.
Incomplete and Inaccurate Resident Documentation: The facility failed to keep accurate records for three residents. One resident with a trach had orders and charting that did not match the actual trach care provided, another resident with ESRD had BP documented on an arm that was ordered not to be used, and a third resident with a fracture had a knee immobilizer and a leg treatment documented as completed when surveyors observed the brace off the resident and the treatment charted before it was finished.
The facility failed to address ongoing concerns raised by the Resident Council regarding the lack of condiments and adherence to menu choices. Despite repeated documentation of these issues in Resident Council Minutes and interviews with residents and staff, the facility did not take sufficient action to resolve the problems, leading to a diminished dining experience for residents.
The facility failed to secure resident PHI on medication carts, as computer screens displaying sensitive information were left open and unattended on two nursing units. Staff interviews confirmed that such screens should not be left open without a nurse present.
The facility failed to implement physician orders and document care for several residents, including not applying prescribed waffle boots for a resident at high risk for pressure ulcers, not obtaining and documenting weights for residents with chronic conditions, and not initiating orders for IV and central line care. These deficiencies highlight significant lapses in adhering to professional standards of practice.
The facility experienced a medication error rate of 23.33%, exceeding the acceptable limit of 5%. Three nurses made errors affecting three residents, including incorrect dosages and missed medications. The Director of Nursing acknowledged the issue, noting that medications should be administered as ordered.
The facility failed to secure medications properly, leaving them unattended on medication carts, at nurses' stations, and in resident rooms. A medication cart was found unlocked on the 3rd floor, and lidocaine patches were left at a resident's bedside. Medications were not labeled with the date opened, and a resident had unauthorized access to Motrin B. These actions were contrary to the facility's policies and procedures.
The facility failed to accurately document care for several residents, including diabetic foot care, oxygen tubing changes, and the use of a hand splint. Additionally, medication administration was not properly documented for a resident with cerebral infarction and vascular dementia. These documentation lapses were confirmed by the Director of Nursing.
A resident with PTSD, anxiety, and depression was found with a bottle of Motrin B at their bedside without an assessment for self-administration. The medical record lacked documentation of an assessment, doctor's order, or care plan for self-administration. A nurse confirmed the resident should not have medications at bedside.
A facility failed to create a baseline care plan within 48 hours for a resident admitted with osteomyelitis, a spinal abscess, and on IV antibiotics. The medical record review showed no plan was developed even five days post-admission. The DON confirmed that the nursing staff should have developed the plan within the required timeframe.
A resident with a history of stroke, diabetes, and depression was not provided with a hand brace or nail trimming as required by their care plan. The resident's hand brace was missing for a month, and staff failed to assist with nail care. Interviews revealed a lack of communication and awareness among staff regarding the resident's needs, with confusion over responsibilities for applying braces and trimming nails.
The facility did not ensure a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team as required. The care plan had not been updated since July, despite an MDS being completed in October. The resident had diagnoses including schizophrenia, anxiety disorder, and depression. The DON confirmed that care plans should be reviewed with each MDS completion.
The facility failed to assist three residents with personal hygiene needs, including cutting fingernails and removing unwanted chin hair, despite their dependence on staff for activities of daily living. One resident with schizophrenia and moderate cognitive impairment was observed with long nails and chin hair, while another resident with stroke and diabetes had long nails, and a third resident with cancer had significant chin hair. The residents expressed embarrassment and a lack of assistance, highlighting a deficiency in the facility's care provision.
A resident with severe cognitive impairment and aphasia was not provided with meaningful activities as per their care plan. Despite being bedbound and nonverbal, the resident was observed multiple times without engagement in activities, and the Activities Director was unaware of this oversight. The resident's Activity Participation Record showed no in-room activities on several dates, indicating a failure to adhere to the care plan.
A resident with chronic conditions was found with outdated oxygen tubing and a dirty concentrator filter, contrary to doctor's orders and professional standards. The facility's policy lacked specific guidelines for equipment maintenance, and the DON could not provide manufacturer's cleaning instructions.
A resident with multiple health conditions did not receive appropriate pain management due to the incorrect application of lidocaine patches. The facility staff applied 5% patches instead of the prescribed 4% patches and placed them on incorrect body sites, contrary to the physician's orders. Interviews with nursing staff confirmed the error, and the DON acknowledged the need for correct verification of patch strength and application site.
A facility failed to develop a trauma-informed care plan for a resident with PTSD within the required timeframe. Despite the facility's policy requiring individualized care plans to address past trauma, no baseline care plan was created within 48 hours of the resident's admission. Interviews with the DON and Regional Social Service Director confirmed the oversight.
A facility failed to review and implement a consultant pharmacist's recommendations for a resident's medication regimen reviews. The resident, with conditions including diabetes and heart failure, had recommendations to discontinue certain medications due to nonuse and evaluate another's necessity. Despite policy requirements, the Director of Nursing did not receive the recommendations, and they were not addressed by nursing staff or the physician.
A nurse failed to follow infection control practices by handling medications with bare hands during a medication pass, potentially contaminating the medications and bottles. Both the nurse and the DON acknowledged the breach of protocol.
Failure to Maintain Resident Dignity and Privacy During Meals and Personal Care
Penalty
Summary
The facility failed to maintain a dignified dining experience for two residents who required assistance with eating. Resident #4, who had osteomyelitis and dysphagia and was dependent for eating, was observed with meal trays left on the over-bed table out of reach and with staff standing next to and over the resident while assisting with meals. On one occasion, a breakfast tray was brought into the room and left on the over-bed table while the resident remained awake in bed, and no staff entered to assist during the observation period. Resident #20, who had metabolic encephalopathy and dysphagia and required partial/moderate assistance for meals, was also observed with staff standing over the resident while feeding and with a meal tray left in the room before assistance was provided. The report also documented a failure to maintain resident privacy for Resident #116. This resident, admitted with diagnoses including history of falling and muscle weakness, was observed sleeping in bed without clothing and with only a sheet up to the waist, leaving the chest visible from the hallway. On another observation, the resident was sitting up in bed with only a brief on after removing the johnny, and the chest was again visible from the hallway. The medical record did not indicate behaviors, and the care plan did not identify behaviors being monitored. Resident #6, who had adult failure to thrive and major depressive disorder and had intact cognition on the most recent MDS, was repeatedly observed with privacy not maintained. The resident was seen lying in bed or sitting on the side of the bed wearing only a brief, with the brief visible from the hallway on multiple occasions. At times the resident was uncovered, and the care plan did not indicate any behaviors. Staff interviews stated that residents should not be visible from the hallway when exposed and that briefs should be covered to maintain privacy and dignity.
Respiratory Supplies Improperly Stored and Oxygen Not Given per Order
Penalty
Summary
Respiratory care and services were not provided in accordance with professional standards for three residents. The facility failed to properly label and store respiratory supplies for Residents #68 and #14, and failed to administer oxygen to Resident #88 according to physician orders. Facility policy for oxygen administration required a physician order, and the record showed orders to label and date disposable oxygen supplies weekly and as needed, with oxygen to be given at 2 liters per minute via nasal cannula for Resident #88. Resident #88 was admitted with acute respiratory failure and COPD, had intact cognition on the most recent MDS, and was documented as using oxygen therapy. Survey observations showed the resident receiving oxygen via nasal cannula at 4.5 lpm, while the physician order called for 2 lpm. The oxygen tubing was observed without a date, the nebulizer was found in the bedside table drawer with other belongings and later in the resident’s bed, and the concentrator was observed out of the resident’s reach. Nursing notes also documented oxygen being turned up to 4 lpm when saturation was low. Staff interviews confirmed that respiratory supplies should be changed weekly, labeled, stored in a bag when not in use, and that oxygen should be administered per physician orders without changing the flow rate without notification and a new order. Resident #68, admitted with COPD and chronic respiratory failure, had an order to change and label nebulizer tubing weekly and as needed. Survey observations found the nebulizer tubing and pipe on the overbed table without a date and not stored in a bag, and the nebulizer itself was repeatedly observed laying on the overbed table rather than being stored. Resident #68 stated staff had changed the tubing because it was not labeled and was weak and popping off the nebulizer. Resident #14, admitted with cerebral infarction, chronic respiratory failure, and dysphagia, had severe cognitive impairment and required suctioning and tracheostomy care. Survey observations found respiratory supplies stored openly on the bedside table, including an unlabeled nebulizer with tubing, and unlabeled suction tubing and a Yankauer that were not covered or protected.
Unlocked Medication Carts
Penalty
Summary
Drugs and biologicals were not secured in accordance with facility policy when medication carts were left unlocked on two of three resident units. The facility policy stated that compartments containing medications and biologicals are to be locked when not in use and that carts used to transport such items are not to be left unattended if open or otherwise available to others. On 12/16/25 at 7:00 A.M., surveyors observed two medication carts on the first-floor unit unlocked with no nurses within eyesight. Later that day at 3:27 P.M., surveyors observed an unlocked medication cart on the second-floor unit with staff members and residents nearby. Nurse #1 was observed entering the second-floor unit carrying takeout food and drinks, and stated during interview that she had left the medication cart unlocked when she went to the first floor to pick up the food and drinks. Corporate Nurse #1 stated during interview that medication carts are to be locked at all times and that the nurse should have locked the cart before leaving the unit.
Homelike Dining Environment Not Maintained
Penalty
Summary
The facility failed to provide a homelike environment during dining on one of three resident units. On the second-floor unit, residents were observed eating breakfast and lunch in the dining room while their meals were served on meal trays. The surveyor observed 4 of 4 residents eating breakfast on trays, 3 of 4 residents eating lunch on trays, 4 of 4 residents eating breakfast on trays, 4 of 4 residents eating lunch on trays, and 3 of 3 residents eating breakfast on trays; on two of the observations, one resident was being assisted by staff. The facility policy titled Homelike Environment, revised February 2021, did not indicate that meals are served in a homelike manner. During interview, the DON stated that meals are not supposed to be served off of trays.
Failure to Implement Ordered Knee Immobilizer Care Plan
Penalty
Summary
Failure to implement a care plan for a knee immobilizer was identified for Resident #2. The resident was admitted in April 2025 with diagnoses including a non-displaced fracture of the right tibial tuberosity, brain cancer, and malnutrition. The MDS assessment indicated the resident was severely cognitively impaired and totally dependent on staff for all activities of daily living. A physician order dated to start 11/12/25 directed staff to apply a right knee immobilizer and check skin integrity every shift, and the care plan included an intervention for the immobilizer as ordered. Surveyor observations on 12/16/25 and 12/17/25 showed the resident lying in bed while the knee immobilizer was on a stool leaning against the wall across the room. Review of the December 2025 progress notes did not show that the resident refused to wear the brace or that the physician was notified. During interviews, Nurse #2 stated nurses are to follow physician orders and that if a resident refuses, the refusal should be documented, a progress note written, and the physician called. The DON stated nurses are to follow physician orders and the care plan at all times, and that refusal should be reflected in the medical record with physician notification.
Failure to Address Dialysis Medication Recommendation
Penalty
Summary
The facility failed to address a dialysis center recommendation for a resident with end stage renal disease and dependence on renal dialysis. Resident #10 had severe cognitive impairment with a BIMS score of 0/15. A dialysis progress note in the dialysis communication book stated that a 30-day supply of sevemar carbonate was provided and instructed that the resident receive the medication with each meal for phosphate control, and that dialysis be called to acknowledge receipt of the medicine. The medical record did not show that the physician had been contacted to approve or deny this recommendation. During record review, the Unit Manager stated that the dialysis recommendation to include sevemar carbonate in the resident’s current medications had not been addressed and that nurses were supposed to review the dialysis communication book after the resident returned from dialysis and contact the physician immediately for approval or denial of recommendations. The DONs stated the dialysis book should be reviewed by nurses after residents return from dialysis and that the physician should have been contacted to approve or deny sevemar carbonate promptly, within 24 hours.
Incomplete and Inaccurate Resident Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents in a sample of 25. For a resident admitted with cerebral infarction, chronic respiratory failure, and dysphagia, the record showed tracheostomy care orders that were not specific to the type of trach in place. The MDS indicated the resident required suctioning and tracheostomy care, and the MAR showed staff signing off daily disposable cannula changes and every-shift trach care, even though a nurse said she was not sure whether the cannula was disposable and only cleaned around the outside of the trach. The DONs stated the resident’s trach did not have an inner cannula at all and that the physician’s orders should have been more specific. For a resident with end stage renal disease and dependence on renal dialysis, the physician’s order stated no blood pressure or drawing on the left arm. The facility’s documentation nevertheless recorded blood pressures as being taken on the left arm on two occasions. During review, the Unit Manager and DONs stated nurses should not have taken blood pressures on that arm and that the documentation in the medical record was inaccurate. The facility policy reviewed also stated not to use the access arm for venipuncture or blood pressure. For a resident with a right tibial tuberosity fracture, brain cancer, and malnutrition, the record showed an order for a right knee immobilizer with skin checks every shift, but surveyors repeatedly observed the immobilizer on a stool across the room while the resident lay in bed. The progress notes did not indicate the resident refused to wear the brace, yet the TAR documented the immobilizer as on during those shifts. In a separate issue, a treatment to the resident’s right leg was observed being performed after the nurse had already signed off that it was completed. Nurses and the DON stated that refusals should be documented and that a treatment should never be documented as completed before it was actually completed.
Failure to Address Resident Council Concerns on Food Service
Penalty
Summary
The facility failed to ensure adequate follow-up on concerns raised by the Resident Council Group, particularly regarding the availability of condiments and adherence to menu choices. During a tour of the facility's kitchenettes, it was observed that condiments such as creamers, butter, salt, and pepper were missing. A resident expressed frustration over the inability to obtain condiments when requested, with staff citing a lack of supply. This issue was corroborated during a Resident Group interview, where residents reported that menus were not followed, and condiments were often missing from meal trays, leading to a diminished dining experience. The Resident Council Minutes from August, September, and October consistently documented concerns about the lack of condiments and non-compliance with menu choices. Despite these recurring issues, the facility did not take sufficient action to address and prevent the recurrence of these problems. Interviews with various staff members, including the Ombudsman, Dietitian, Food Service Director, and Administrators, revealed awareness of the ongoing issues but no effective resolution. The facility's policies on Resident Council and Grievances/Complaints outline procedures for addressing resident concerns, but these were not adequately implemented. The Grievance Officer is responsible for investigating complaints and ensuring corrective actions, yet the residents' grievances about food service were not resolved. The lack of condiments and adherence to menu choices remained unaddressed, indicating a failure in the facility's response to resident feedback.
Failure to Secure Resident PHI on Medication Carts
Penalty
Summary
The facility failed to ensure the security and confidentiality of resident protected health information (PHI) on two of its three nursing units. Observations by the surveyor revealed that computer screens on medication carts were left open and unattended, displaying residents' names, photos, and identifying information. This occurred on multiple occasions across different floors, with no nurse present to monitor the information being displayed. Interviews with facility staff, including a Unit Manager and the Director of Nursing (DON), confirmed that the medication administration computer screens should not be left open unless a nurse is present. The Unit Manager acknowledged the issue when observed by the surveyor, and the DON reiterated that resident information should only be visible to the nurse attending the medication cart. These lapses in protocol led to the exposure of sensitive resident information, violating the facility's policy on confidentiality and personal privacy.
Deficiencies in Implementing Physician Orders and Documentation
Penalty
Summary
The facility failed to meet professional standards of practice for five residents, leading to deficiencies in care. For one resident, the facility did not implement a physician's order to offload heels and apply waffle boots, despite the resident being at very high risk for developing pressure ulcers. Observations over two days showed the resident lying in bed with feet flat on the bed and without the prescribed waffle boots. The unit manager confirmed the resident's heels were not offloaded, and the boots were not applied as ordered. Another resident, who was cognitively intact and at risk for weight fluctuations due to chronic conditions, did not have weights obtained as ordered. The resident's care plan and physician's orders specified daily weights, but the last recorded weight was over a week prior to the survey. Interviews with staff revealed a lack of communication and documentation regarding the resident's weight monitoring, with the unit manager acknowledging the failure to obtain daily weights as ordered. Additional deficiencies included the failure to document weights for a resident with a history of diabetes and heart failure, despite orders for twice-weekly weights. The facility also did not implement physician orders for monitoring a peripheral IV site for another resident, and there were no orders or care plans for the care of a central line for a resident with lung cancer. These lapses in following physician orders and documenting care highlight significant gaps in the facility's adherence to professional standards of practice.
Medication Error Rate Exceeds Acceptable Limits
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 23.33% error rate observed during a survey. Three nurses were observed making seven errors out of 30 medication administration opportunities. These errors affected three residents, each with specific medical conditions. Resident #15, diagnosed with cancer, muscle weakness, and anxiety disorder, did not receive Aspirin and Magnesium Oxide as per the doctor's orders. Resident #22, with heart disease and stroke, received incorrect dosages of Senna, Ferrous Gluconate, and Folic Acid, and did not receive Famotidine. Resident #48, diagnosed with osteomyelitis, opioid dependence, and liver failure, received an incorrect dosage of Acetaminophen. The facility's policy on administering oral medications, revised in October 2010, was not adhered to, as nurses failed to confirm medication names and doses with the medication administration record (MAR). The Director of Nursing acknowledged that the medication error rate was above acceptable limits and emphasized that all medications should be administered as ordered by the physician. The report highlights the specific instances where the facility's procedures were not followed, leading to the observed medication errors.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly secured, as observed by surveyors. Medications were left unattended on medication carts, at nurses' stations, and in resident rooms. Specifically, medication cards containing gabapentin and duloxetine were found on an unlocked medication cart on the 1st floor, and medication cards with hyoscyamine, losartan, and famotidine were left unattended at the nurses' station. Additionally, medication cups with various medications were left on a resident's bedside table without supervision. On the 3rd floor, a medication cart was observed unlocked and unattended, with several staff members and a resident nearby. The Director of Nursing confirmed that medication carts should be locked when unattended. Furthermore, lidocaine patches were repeatedly found unattended at a resident's bedside, contrary to the facility's policy that they should be stored in the medication cart. The facility also failed to label medications with the date they were opened. A Wixela inhaler and a bottle of Tuberculin derivative were found open without a date, despite the manufacturer's instructions to discard them one month after opening. Additionally, a resident was found with a bottle of Motrin B at their bedside, although they had not been assessed for self-administration of medication. The resident admitted to placing the bottle in their backpack, and a nurse confirmed that the resident was not supposed to have medications at their bedside.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to accurately document care and treatment in the clinical records for four residents. For one resident with diabetes mellitus and dementia, the facility did not document diabetic foot care on multiple occasions as required by the physician's orders. The Director of Nursing confirmed that the documentation was incomplete for specific dates. Another resident with chronic obstructive pulmonary disease, heart disease, and kidney disease had inaccurate documentation regarding the change of oxygen tubing. The Medication Administration Record indicated that the tubing was changed on certain dates, but observations showed that the tubing was not replaced as documented. The Director of Nursing acknowledged that the documentation was incorrect. A third resident, who had a stroke and was dependent on others for activities of daily living, was observed without the prescribed hand splint. The resident reported that the splint had been missing for about a month, and the facility's records inaccurately indicated that the splint was in use. Additionally, a resident with cerebral infarction and vascular dementia had multiple instances where medication administration was not documented. The Director of Nursing stated that nurses are expected to document medication administration or refusals, which was not done in this case.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications without a proper assessment. A resident, admitted with diagnoses including post-traumatic stress disorder, anxiety disorder, and depression, was observed with a bottle of Motrin B on their over-the-bed table. The resident admitted to placing the bottle in their backpack. The medical record did not show any assessment for the resident's ability to self-administer medication, nor was there a doctor's order or care plan for self-administration. A nurse confirmed that the resident was not supposed to have medications at bedside.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident was admitted with serious medical conditions, including osteomyelitis, a spinal abscess with drains, and was receiving intravenous antibiotics. Despite these needs, a review of the medical record showed that no baseline care plan was created within the specified timeframe, and even five days post-admission, the plan had not been developed. During an interview, the Director of Nursing acknowledged that the nursing staff should have created a baseline care plan within the required 48-hour period.
Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to implement a resident-centered care plan for a resident with a history of stroke, diabetes, and depression, who was admitted in June 2023. The resident was dependent on assistance for activities of daily living (ADLs) and required a left hand splint and regular fingernail trimming to prevent injury. Despite a doctor's order and a care plan specifying the use of a hand brace and the need for nail trimming, the resident was observed without the hand brace and with long, jagged fingernails. The resident reported that the hand brace had been missing for about a month after being sent to laundry and not returned, and that staff had not assisted with nail trimming. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's needs. A CNA stated that it was their responsibility to cut fingernails and apply braces, while the Unit Manager was unaware of the resident's condition. The Physical Therapist admitted to mistakenly giving the resident's brace to another resident and failing to reorder it. Additionally, there was confusion about who was responsible for nail trimming, with the Unit Manager stating it was the podiatrist's role, while the DON indicated it was the CNAs' responsibility. The Unit Secretary confirmed that the resident had not been offered consent to see a podiatrist.
Failure to Review and Revise Care Plan by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised by the interdisciplinary team as required. The facility's policy mandates that care plans be reviewed and updated at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. The resident in question was admitted with diagnoses including schizophrenia, anxiety disorder, and depression. An MDS was completed for the resident on October 22, 2024, but the care plan had not been reviewed since July 30, 2024, and the target dates for all goals had not been updated. During an interview, the Director of Nursing confirmed that care plans should be reviewed each time the MDS is completed, and new target dates should be set for all goals.
Failure to Assist Residents with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were dependent on staff for personal care. Resident #14, who was admitted with schizophrenia, anxiety disorder, and depression, exhibited moderate cognitive impairment and required substantial assistance with personal hygiene. Despite this, the resident was observed multiple times with long, jagged fingernails and inch-long chin hair, which the resident expressed embarrassment about and stated they could not manage without staff assistance. The care plan indicated a need for assistance with daily hygiene, yet there was no indication of refusal of care by the resident. Resident #77, with a history of stroke, diabetes, and depression, was totally dependent on staff for ADLs due to impairments in both upper and lower body. The resident was observed with long, jagged fingernails and expressed a need for help, which had not been provided. The care plan required nails to be trimmed to prevent injury, but there was confusion among staff about responsibility for nail care, particularly for diabetic residents. Resident #15, diagnosed with cancer and muscle weakness, was also totally dependent on staff and was observed with significant chin hair, which the resident found embarrassing and stated they did not receive help to remove. These observations indicate a failure in the facility's adherence to its policy on supporting ADLs for dependent residents.
Failure to Provide Meaningful Activities for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide a meaningful activity program for a resident who was admitted with diagnoses including malignant neoplasm of the frontal lobe and aphasia. The resident was severely cognitively impaired, requiring assistance with daily activities and was primarily nonverbal. Despite having a care plan that included daily room visits and the use of an interpreter to address communication barriers, the resident was observed multiple times resting in bed without any engagement in activities. The resident's family member reported that staff did not offer in-room activities or turn on the TV or radio for the resident. Observations by the surveyor confirmed that the resident was often left in a dimly lit room with no active engagement from staff, as the TV and radio were not turned on. The Activities Director was unaware that the resident had not received in-room activities, despite having volunteers and staff available to provide such services. The Activity Participation Record showed no in-room activities provided on several dates, indicating a lack of adherence to the resident's care plan and a failure to meet the resident's needs for meaningful engagement.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident. The deficiency involved a resident with chronic obstructive pulmonary disease, heart disease, and kidney disease, who was observed receiving oxygen via nasal cannula attached to an oxygen concentrator. The oxygen tubing was dated over a month old, despite a doctor's order to change nasal cannula weekly and all disposable oxygen supplies every week. Additionally, the concentrator filter was observed to be covered with a gray fuzzy substance, indicating it had not been cleaned as required. The facility's policy on oxygen administration did not specify the frequency for changing tubing or cleaning the concentrator filter, and the Director of Nursing was unable to provide the manufacturer's instructions for cleaning the filter.
Inappropriate Pain Management Due to Incorrect Lidocaine Patch Application
Penalty
Summary
The facility failed to provide appropriate pain management for a resident by not adhering to the physician's orders regarding the administration of lidocaine patches. The resident, who was admitted with conditions including diabetes, atrial fibrillation, heart failure, and pain, was observed to have lidocaine 5% patches applied to the right hip and right shoulder, contrary to the physician's orders which specified the use of 4% patches on the left hip and right shoulder. This discrepancy was noted over several days, indicating a consistent failure to follow the prescribed pain management regimen. Interviews with nursing staff revealed a lack of adherence to the correct application of the lidocaine patches. Nurse #4 and Nurse #5 both confirmed the use of 5% patches, which was not in line with the physician's orders. The Director of Nursing acknowledged that the nursing staff should verify the correct strength and application site of the patches before administration. This oversight in following the prescribed pain management plan resulted in the resident not receiving the appropriate treatment as ordered by the physician.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident diagnosed with post-traumatic stress disorder (PTSD) upon admission. The facility's policy, revised in August 2022, mandates that individualized care plans addressing past trauma should be developed in collaboration with the resident and family, aiming to identify and decrease exposure to potential triggers. The resident, admitted in November 2024 with diagnoses including PTSD, osteomyelitis, spinal abscesses, and intravenous antibiotic use, did not have a baseline care plan for PTSD developed within 48 hours of admission. As of five days post-admission, the care plan was still not in place. Interviews with the Director of Nursing and the Regional Social Service Director confirmed that the nursing staff should have developed a baseline care plan for the resident's PTSD within 24 to 48 hours of admission.
Failure to Review and Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to review and act upon the consultant pharmacist's recommendations for the monthly medication regimen reviews (MRR) for a resident. Specifically, the nursing staff and the physician did not review the pharmacist's recommendations for the resident in September and October. The facility's policy requires that the consultant pharmacist provide a written report to the attending physicians within 24 hours of the MRR, and if no action is taken, the pharmacist should contact the medical director or administrator. However, the Director of Nursing (DON) stated that he did not receive the pharmacy recommendations for these months, and the recommendations were not addressed by the nursing staff or the physician. The resident involved was admitted with diagnoses including diabetes, atrial fibrillation, heart failure, and pain, and was cognitively intact as per the Minimum Data Set (MDS) assessment. The pharmacist's progress notes recommended discontinuing certain medications due to nonuse and evaluating the continued need for another medication. Despite these recommendations, the active physician's orders still included the medications in question. Interviews with nursing staff revealed a lack of communication and follow-up on the pharmacy recommendations, with the Unit Manager acknowledging that the recommendations should have been reviewed and implemented by now.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection control practices during a medication pass, as observed by a surveyor. Nurse #4 was seen pouring unit dose medications into her hand before transferring them to a medication cup, which could potentially contaminate the medications. Additionally, Nurse #4 poured medications from bottles into her bare hand, placed some into medication cups, and returned unused medications to the bottles, risking contamination of the medication bottles. During interviews, both Nurse #4 and the Director of Nursing acknowledged that medications should not be touched with bare hands, indicating a lapse in following the facility's infection control policy.
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 1,278 citations issued within 25 miles in the last 12 months — including the 4 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 Brookline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brighton Post Acute Care | 0.8 mi | ★★★★★ | 12 | 0 |
| Sherrill House | 1.1 mi | ★★★★★ | 9 | 0 |
| Benjamin Healthcare Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Spaulding Nursing And Therapy Center - Brighton | 1.4 mi | ★★★★★ | 0 | 0 |
| Armenian Nursing & Rehabilitation Center | 2.2 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.