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 Care One At Essex Park during CMS and state inspections, most recent first.
CNA Performed Manual Disimpaction Outside Scope of Practice: A resident with multiple cardiac and chronic conditions reported that a CNA inserted a finger into the rectum to remove stool after the resident felt constipated and said something was stuck. The resident said it was painful, and the DON later stated the CNA admitted doing it and said she thought she was helping, even though the facility’s policy said nurses and CNAs are not to perform manual digital disimpaction.
A resident experienced significant weight loss after their gastrostomy tube was dislodged and not replaced. The facility failed to monitor the resident's weight, notify the physician, and implement new nutritional interventions, leading to severe malnutrition and dehydration.
A resident dependent on enteral nutrition experienced dehydration and significant weight loss after their feeding tube was dislodged. The facility failed to monitor and maintain the resident's hydration and nutrition, leading to rehospitalization. Interviews revealed a lack of communication and monitoring among staff.
A facility failed to document the initial catheter size and balloon size for a resident with an indwelling Foley catheter and did not include these details in the physician's orders for catheter changes. Interviews revealed that the facility's policy did not require such documentation, leading to improper catheter management.
A resident dependent on tube feeding experienced significant weight loss, but the facility failed to notify the physician as required. Interviews revealed that the dietician and nursing staff did not communicate the weight changes, leading to a delay in treatment.
The facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate. Errors included administering the incorrect form and type of medications to two residents, as observed by surveyors. The DON confirmed the errors, which were not in accordance with physician orders.
The facility failed to ensure that medication carts on two units were properly secured. On the [NAME] Unit, a medication cart was observed unlocked and unattended twice, with Nurse #3 admitting to the oversight. Similarly, on the [NAME] Unit, a medication cart was found unlocked and unattended near a resident. Both instances were confirmed by the DON and nursing staff.
The facility failed to maintain accurate medical records for a resident with Parkinson's disease, dementia, and dysphagia. Documentation for ADLs was incomplete for 21 shifts over a 90-day period, despite the resident's cognitive impairment and total dependence on staff. Interviews with a CNA and the DON confirmed that all ADLs should be documented daily.
CNA Performed Manual Disimpaction Outside Scope of Practice
Penalty
Summary
The facility failed to ensure care and treatment were provided in accordance with acceptable standards of practice when a CNA used her fingers to digitally disimpact a resident, which was not within a CNA’s scope of practice or job description and was not a procedure the facility allowed CNAs to perform. The resident had been admitted with severe aortic stenosis, atrial fibrillation, hypertension, diabetes, and a history of stroke without residual deficits, and the record noted mild cognitive impairment with some confusion but that the resident was alert and oriented x3, with clear speech and the ability to understand and be understood. According to the report submitted by the facility, the resident told the HCP that a CNA had disimpacted him/her during the night over the weekend and that it was painful. The Nursing Supervisor later spoke with the resident, who repeated that a CNA had used her fingers to pull stool from the resident’s rectum. The Nursing Supervisor assessed the resident and observed no skin issues or areas of trauma, and she informed the DON and ADON of the allegation. During interviews, the ADON stated the resident reported being constipated and said that early in the morning on the overnight shift, after asking a CNA for help to the bathroom and saying it felt like something was stuck in the rectum, the CNA inserted her finger into the rectum to help move the bowels. The DON stated the CNA admitted she had disimpacted the resident and said she thought she was helping and did not know it was not within CNA scope of practice. The DON also stated the facility’s policy was that nurses and CNAs are not to perform manual digital disimpaction and that nursing is to notify the physician if there is an issue.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in significant weight loss. The resident, who had diagnoses including Parkinson's disease, dementia, dysphagia, and severe protein-calorie malnutrition, was dependent on tube feeding. The resident's gastrostomy tube was accidentally removed and not replaced, leading to a significant weight loss that was not promptly addressed by the facility staff. The facility's policy required monitoring of resident weights for undesirable weight loss and timely intervention by the dietician, but these steps were not adequately followed in this case. The resident's weight was not properly monitored after the gastrostomy tube was dislodged, and the physician was not notified of the significant weight loss that occurred. The resident's weight dropped from 125 lbs to 119.4 lbs within three days of the tube being dislodged, and further declined to 109 lbs by 3/20/24. Despite this significant weight loss, no new nutritional interventions were implemented, and the physician was not informed of the resident's deteriorating condition. The resident's meal plan remained unchanged, and the dietician did not closely monitor the resident's daily food consumption. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's nutritional needs. The medical director was not fully aware of the resident's inadequate intake and rapid weight loss, and the dietician did not effectively communicate the urgency of the situation. The resident was eventually transferred to the hospital with severe malnutrition and dehydration, highlighting the facility's failure to provide adequate nutritional care and timely medical intervention for the resident.
Failure to Monitor Hydration and Nutrition for Resident with Dislodged Feeding Tube
Penalty
Summary
The facility failed to ensure that fluids were administered and monitored to maintain acceptable parameters of hydration for a resident who received enteral nutrition via a gastrostomy tube. The resident's tube was dislodged, and attempts to replace it were unsuccessful. Despite the resident being dependent on tube feeding for daily caloric intake, the facility did not have a plan in place to maintain the resident's intake and hydration, leading to clinical signs of dehydration and the need for intravenous fluids. The resident was eventually rehospitalized due to dehydration and significant weight loss. The facility's policies on enteral nutrition feedings and hydration were not adequately followed. The resident's medical record did not indicate monitoring for intake or output after the tube feed had dislodged. The resident's weight and lab results showed significant deterioration in health, including high sodium levels and poor kidney function. The medical director and nursing staff failed to ensure the resident received adequate hydration and nutrition, relying on inaccurate reports of the resident's intake. Interviews with the medical director, registered dietician, and director of nursing revealed a lack of communication and monitoring. The medical director admitted to a delay in sending the resident to the hospital, while the registered dietician and director of nursing pointed to each other for responsibility in monitoring the resident. The resident's condition worsened over 18 days, culminating in a hospital admission for dehydration and significant weight loss.
Failure to Document and Follow Physician Orders for Foley Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and service for an indwelling Foley catheter for a resident with moderate cognitive impairment. The resident was admitted with diagnoses including retention of urine and obstructive and reflux uropathy. The facility did not document the initial catheter size and balloon size upon admission, and the physician's orders for changing the catheter did not specify the required catheter size and balloon size. This lack of documentation and specific orders could lead to improper catheter management. During interviews, a nurse confirmed that physician orders for urinary catheters should include the catheter and balloon sizes. The Director of Nursing also acknowledged that their policy did not require orders to indicate these sizes, and in the event of reinsertion, they would start with a smaller size. This oversight in documentation and policy adherence was identified as a deficiency by the surveyors.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss for a resident who was totally dependent on tube feeding for daily nutritional needs. The resident, admitted with diagnoses including Parkinson's disease, dementia, and dysphagia, experienced a weight drop from 125 lbs on March 7, 2024, to 119.4 lbs on March 11, 2024, and continued to lose weight. Despite the care plan's directive to notify the physician of significant weight changes, there was no documentation indicating that the physician was informed of the resident's weight loss during this period. Interviews revealed that the dietician acknowledged the resident's reliance on tube feeding and stated that the physician should have been notified of the weight loss sooner. The Medical Director confirmed that he was not alerted to the significant weight loss and would have sent the resident to the hospital for further intervention had he been informed. The Director of Nursing indicated that the dietician was responsible for monitoring the resident's weight and should have notified the physician of the changes. This lack of communication resulted in a delay in treating the resident's inadequate intake.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5%, resulting in a medication error rate of 10.34%. Specifically, for Resident #30, the nurse administered the incorrect form of aspirin (enteric coated instead of chewable) and the incorrect type of multivitamin (with minerals instead of without). Resident #30 had diagnoses including asthma and dementia, with a moderate cognitive impairment as evidenced by a BIMS score of 12 out of 15. The errors were acknowledged by Nurse #3 and confirmed by the Director of Nursing (DON), who stated that medications should be given as ordered by the physician. For Resident #138, the nurse administered a multivitamin with iron instead of the prescribed multivitamin with minerals. Resident #138 had diagnoses including bladder cancer and a urinary tract infection, with a BIMS score of 15 out of 15, indicating cognitive impairment. The DON confirmed that the administration of the multivitamin with iron was an error, as iron requires a specific order. These errors were observed during a survey, and the facility's policy on administering medications was not followed as prescribed.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional standards of practice. Specifically, the medication carts on two of four units were observed to be unlocked and unattended. On the [NAME] Unit, the surveyor observed the medication cart on the A side unlocked and unattended at 9:00 A.M. and again at 9:19 A.M. Nurse #3 admitted to leaving the cart unlocked and unattended, which was confirmed by the Director of Nursing during an interview. Similarly, on the [NAME] Unit, the medication carts were observed to be unlocked and unattended at 6:37 A.M., with a resident near the unlocked cart. Nurse #2 confirmed that the carts should be locked if unattended, and this was reiterated by the Director of Nursing. The facility's policy titled Medication Labeling and Storage, revised February 2023, mandates that all medications and biologicals be stored in locked compartments under proper conditions and that medication carts should be locked when not in use. The nursing staff is responsible for maintaining medication storage, and carts should not be left unattended if open or potentially available to others. The observations and interviews indicate a failure to adhere to these policies, leading to the deficiency noted in the report.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for one resident out of a sample of 34. Specifically, the facility did not complete daily documentation for Activities of Daily Living (ADLs) for a resident diagnosed with Parkinson's disease, dementia, and dysphagia. The resident's Minimum Data Set (MDS) indicated cognitive impairment and total dependence on staff for care. A review of the eating documentation section for February, March, and April 2024 revealed incomplete documentation for 21 shifts out of 90 days. Interviews with a Certified Nursing Assistant (CNA) and the Director of Nursing confirmed that all ADLs should be documented daily, and no sections should be left incomplete.
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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 Beverly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blueberry Hill Rehabilitation And Healthcare Ctr | 0.6 mi | ★★★★★ | 12 | 0 |
| Ledgewood Rehabilitation And Nursing Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Brentwood Rehabilitation And Healthcare Ctr (the) | 3.1 mi | ★★★★★ | 6 | 0 |
| New England Homes For The Deaf, Inc | 3.3 mi | ★★★★★ | 0 | 0 |
| Twin Oaks Center | 3.8 mi | ★★★★★ | 0 | 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.